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ESSAYS 


CLINICAL    MEDICINE 


BEING 

REPRINTS  OF  PAPERS  PUBLISHED  AT  VARIOUS  TIMES  IN  THE 

"AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES  " 


BY 

BEVERLEY  ROBINSON,  A.M.,  M.D.  (Paris) 

CLINICAL    PROFESSOR  OF  MEDICINE  AT    UNIVERSITY  AND    BELLEVUE    HOSPITAL    MEDICAL 

COLLEGE  ;  ATTENDING   PHYSICIAN  TO  ST.  LDKE'S  HOSPITAL  ;  CONSISTING 

PHYSICIAN  TO  THE  CITY  (CHARITY)   HOSPITAL,   NEW  YORK. 


PHILADELPHIA 

WILLIAM    J.  DORNAN 
1903 


THESE  ESSAYS 

NOW    REPRINTED     IN     COLLATED     FORM 
ARE 

AFFECTIONATELY  INSCRIBED 

TO    MY 
FORMER    HOUSE    PHYSICIANS    OF    ST.    LUKE'S    HOSPITAL 

NEW   YORK,    FEBRUARY,     1903 


CONTENTS. 


Creasote  as  a  Remedy  in  Phthisis  Pulmonalis.    (January,  1889.)         .  9 
On  the  Course  and  Treatment  of  Certain  Ursemic  Symptoms.   (Octo- 
ber, 1893.) 24 

A  Contribution  to  the  Treatment  of  Organic  Disease  of  the    Heart. 

(December,  1894.) 35 

Etiology  and  Treatment  of  Certain  Kinds  of  Cough.   (November,  1895.)  58 

Prognosis  in  Heart  Disease.     (December,  1899.) 68 

Minor  Forms  of  Cardiac  Dilatation.     (August,  1900.)           ...  81 

Clinical  Study  of  Acute  Myocarditis.     (March,  1901.)          ...  89 
Chronic  Myocarditis  and  Fatty  Degeneration  of  the  Heart.     (June, 

1901.) 104 

Angina  Pectoris.     (February,  1902.) .  119 

Tuberculous  Pericarditis  :    Followed    by  Remarks  upon   Paracentesis 

and  Incision.     (June,  1902.)         .         .         .         .         .         .         .         .  135 

A  Study  of  Some  Cirrhoses  of  the  Liver.     (February,  1903.)      .         .  149 


CREASOTE  AS  A  REMEDY  EN  PHTHISIS 
PULMONAL1S.1 


The  use  of  creasote  in  the  treatment  of  phthisis  pulmonalis  dates 
back  to  1830,  the  year  in  which  its  was  discovered  by  Reichenbach,  of 
Blausko,  in  Moravia.  Later  on,  it  fell  into  disuse,  like  some  other  valu- 
able medicaments,  and  for  nearly  thirty  years  previous  to  1877  it  was 
practically  of  little  or  no  importance  in  the  therapeutics  of  pulmonary 
disease.  At  the  date  just  referred  to,  Drs.  Bouchard  and  Gimbert  again 
revived  interest  in  this  drug  by  publishing  a  very  complete  article  in 
the  Gazette  Hebdomadaire,  of  Paris/'  on  its  beneficial  effects  in  consump- 
tion. They  claimed  for  it  excellent  results,  and  for  careful,  learned,  and 
honest  observers,  their  account  was  as  nearly  enthusiastic  as  thorough 
work  is  apt  to  be. 

Shortly  after  reading  of  the  observations  or  Bouchard  and  Gimbert, 
I  began  to  use  creasote  in  the  treatment  of  pulmonary  phthisis,  and  in 
a  clinical  lecture  delivered  at  the  Bellevue  Hospital  Medical  College, 
and  published  in  the  Medical  Record  of  September  21, 1878,  page  223, 1 
mention  in  what  manner  I  have  used  it  and  with  what  results  in  the 
following  terms : 

"  For  several  months,  both  in  the  Out-door  Department  of  the  New  York 
Hospital,  at  Charity  Hospital  and  elsewhere,  I  have  given  dessert-spoonful 
doses  of  the  mistura  creasoti  of  our  Pharrnacopceia  to  lessen  the  quantity  of 
sputa  in  phthisis.  I  am  very  much  pleased  with  this  remedy,  and  believe 
it  merits  a  very  extensive  trial.  No  doubt,  in  lessening  the  abundance  of 
expectoration,  it  also  diminishes  the  frequency  of  cough." 

At  that  time,  I  would  add,  I  regarded  creasote  as  being  only  a  good 
anti- catarrhal  agent,  to  be  ranked  high  amongst  some  analogous  remedial 
substances  whose  main  action  consisted  in  the  diminution  of  the  amount 
of  purulent  sputa,  but  which  had  little  or  no  curative  effect  upon  the 
essential  lesions  of  pulmonary  phthisis,  as  we  understand  them. 

From  1878  until  1885,  the  year  when  Jaccoud's  treatise  on  pulmonary 
phthisis,  translated  by  Montague  Lubbock,  was  published,  I  continued 
to  make  use  of  creasote  from  time  to  time,  but  without  watching  care- 
fully its  effects,  or  believing  that  we  had  discovered,  in  the  employment 

1  Read  before  the  Association  of  American  Physicians,  Washington,  1888. 

2  Pages  486,  504,  522,  and  620. 

2 


10  CREASOTE    IN    PHTHISIS    PULMONAL1S. 

of  this  drug,  a  very  valuable  addition  to  our  usual  medicinal  means  of 
treating  pulmonary  phthisis.  Jaccoud's  statements  about  the  advan- 
tages resulting  from  the  internal  exhibition  of  creasote  in  this  disease 
impressed  me  very  much,  and  from  the  time  I  first  read  them  to  the 
present  date  I  have  prescribed  creasote  very  frequently  in  pulmonary 
phthisis,  and,  usually,  with  marked  beneficial  effects. 

About  the  period  when  Jaccoud's  work  was  first  published  the  em- 
ployment of  antiseptic  inhalations  in  the  treatment  of  this  disease  inter- 
ested me,  and  amongst  the  substances  of  which  I  made  extensive  use 
none  seemed  to  me  of  more  value  than  creasote.  A  great  deal  of  what 
I  could  even  now  say  with  truth,  in  regard  to  the  utility  and  evident 
results  of  antiseptic  inhalations  in  the  treatment  of  pulmonary  phthisis, 
can  be  found  by  reference  to  a  paper  read  by  me  on  this  subject,  at 
the  second  annual  meeting  of  the  American  Climatological  Association, 
held  in  New  York  City,  May  27,  1885,  and,  also,  in  a  clinical  lecture 
entitled  "  Modern  Methods  of  Treatment  of  Pulmonary  Phthisis,"1  which 
was  delivered  before  the  students  of  the  Bellevue  Hospital  Medical 
College,  October  27,  1885,  and  was  published  in  the  New  York  Medical 
Journal  of  November  14,  1885,  page  535.  In  the  issue  of  the  Journal 
of  that  date  the  following  occurs : 

"  I  have  employed  at  different  times  a  large  number  of  inhaling  fluids  and 
many  different  combinations.  The  fluid  and  combination  to  which  I  now 
give  the  preference  are  creasote  and  alcohol,  equal  parts,  to  which  I  also  fre- 
quently add  a  like  proportion  of  spirits  of  chloroform.  This  combination  is 
certainly  very  useful  in  allaying  cough  and  modifying  the  quantity  and  quality 
of  the  sputa  in  pulmonary  phthisis.  I,  therefore,  recommend  it  very  warmly. 
The  alcohol  is  added  to  the  creasote  for  the  double  purpose  of  diluting  it  and 
making  it  more  volatile;  the  spirits  of  chloroform  are  added,  in  view  of  the 
experience  of  Dr.  J.  Solis-Cohen,  of  Philadelphia,  to  diminish  local  irrita- 
tion and  excessive  cough.  .  .  .  Properly  and  judiciously  employed,  the 
creasote  inhalant  relieves  symptoms  notably,  and  in  the  beginning,  at  least, 
of  pulmonary  phthisis  is,  I  believe,  a  means  of  decided  utility,  so  far  as  the 
possible  arrest  of  the  disease  is  concerned.  It  is  important  that  beechioood 
creasote  be  employed.  .  .  .  Precisely  the  way  in  which  creasote  is  most 
useful  is,  perhaps,  difficult  to  state.  By  its  antiseptic  action  it  is  possibly 
destructive  of  bacilli ;  by  its  local  action  and  general  effect  it  is  certainly  ot 
value  in  combating  catarrhal  conditions.  Where  purulent  cavities  exist  it 
tends  to  destroy,  or  neutralize,  putridity.  These  are  certainly  sufficiently 
good  reasons  for  its  use  without  pursuing  the  inquiry  further.  At  all  events, 
these  inhalations  do  good.  The  physician  notices  it,  and  the  patient  affirms 
it.  In  many  instances  they  allay  cough  better  than  any  cough  mixture,  and 
they  are  certainly  free  from  the  great  objection  of  destroying  appetite,  as 
opium  and  morphine  so  frequently  do." 

I  mention  the  preceding  facts  to  show,  as  I  trust  I  have  been  able  to 
do,  that  my  interest  in,  and  experience  of,  the  good  effects  of  creasote 
in  the  treatment  of  pulmonary  phthisis  date  back  already  several  years, 
and  is  by  no  means  the  outgrowth  of  later  observations  which  have  come 

1  This  paper  was  published  in  the  Transactions  of  the  Association.    D.  Appleton  &  Co.,  New 
York,  1886. 


CREASOTE    IN     PHTHISIS    PULMONALIS.  11 

to  us  mainly  from  Germany,  and  at  the  hands  of  Frantzel,'  Sommer- 
brodt,"  Guttmann,3  Lublinski,'  etc. 

And  here  I  would  like  to  add  a  word  of  praise  for  that  very  distin- 
guished therapeutician,  Dr.  Dujardin  Beaumetz,  who,  in  his  remarkable 
work  on  clinical  therapeutics,5  has  given  corroborative  testimony  which, 
in  my  mind,  has  increased  the  importance  of  creasote  as  a  valuable 
therapeutic  addition  to  our  ordinary  arsenal  for  the  relief  of  phthisical 
patients.  In  the  latest  edition,  also,  of  the  admirable  work  of  It. 
Douglas  Powell,6  will  be  found  remarks  of  considerable  value  with 
respect  to  the  indications  for  the  employment  of  this  drug.  In  this 
author's  observation,  he  has  been  led  strongly  to  doubt  whether  creasote 
can  be  given  during  the  hectic  stage  in  sufficient  quantities  to  influence 
pyrexia  without  running  a  grave  risk  of  setting  up  gastro-intestinal  irri- 
tation and  destroying  appetite.  He  regards  it  as  being  of  more  value 
in  apyrexial  conditions ;  he  adds,  however,  that  "  when  there  is  much 
local  disturbance  of  stomach  and  upper  bowel,  small  doses  of  creasote 
in  combination  with  opium  are  sometimes  of  great  service." 

I  do  not  wish  further  to  weary  attention  with  mere  bibliographical 
research,  and  refer  to  all  the  observations  which  have  been  made  in 
regard  to  the  creasote  treatment  of  pulmonary  phthisis  ;  suffice  it  to  say, 
that  it  has  been  largely  praised ;  that  several  late  observers,  notably 
Frantzel,  Sommerbrodt,  and  Guttmann,  are  inclined  to  regard  it  as 
directly  curative  of  pulmonary  phthisis,  at  least  in  its  initial,  or  first, 
stage ;  that  others,  on  the  contrary,  are  less  favorably  disposed  toward 
it,  and  frankly  confess  that  they  have  been  disappointed  in  it ;  and  have 
discovered  no  reliable  evidence  to  show  that  creasote  has  any  marked 
beneficial  action  over  and  beyond  what  may  be  obtained  from  several 
other  anti-bacillary  agents. 

Naturally,  the  discovery  of  the  bacillus  tuberculosis  by  Koch,  in 
1882,  made  those  observers  who  gave  it  internally,  or  who  made  use  ot 
it  in  inhalations,  or,  in  some  rare  instances,  by  hypodermatic  or  intra- 
pulmonary  injections,7  since  that  date,  endeavor  to  establish  its  utility 
mainly  upon  its  antiseptic  properties  and  upon  its  power  "  to  retard  the 
local  development  of  tuberculosis,"  which  is  probable,  if  the  experiments 


1  Deutsche  rued.  Wochenschrift,  No.  14,  1887. 
-  Berliner  klin.  Wochenschrift,  No.  15,  1887. 

3  Zeitschrift  f.  klin.  Med.,  Berlin,  1887,  xiii.,  488-494;  and  Boston  Medical  and  Surgical 
Journal,  August  18, 1887,  p.  161. 

4  Deutsche  med.  Wochenschrift,  Leipzig,  1887,  xiii.  829. 

5  Le<;ons  de  Clinique  Therapeutique,  t.  2.    Paris,  1885,  4th  edition,  p.  549  et  seq. 

6  Diseases  of  the  Lungs  and  Pleurte,  etc.  William  Wood  &  Co. ,  New  York,  1886,  3d  edition, 
p.  307. 

'<  See  Wien.  med.  Presse,  1888,  xxix.  87  ;  Medical  News,  June  23,  1888,  p.  696  ;  The  American 
Journal  of  the  Medical  Sciences,  February,  1888,  p.  179;  New  Medications,  by  Beaumetz, 
p.  192;  Lyon  Medical,  1885. 


12  CREASOTE    IN    PHTHISIS    PULMONALIS. 

on  animals  of  Coze  and  Simor,  in  1883,  can  be  relied  on.1  Hippolyte 
Martin,2  also,  found  that  creasote  failed  to  destroy  the  bacillus  of  tuber- 
culosis, even  in  the  proportion  of  1  per  1000.  This  fact  is  said  by  him 
to  be  equally  true  of  salicylic  acid  (solution  of  5  per  cent.) ;  bromine 
(1  per  10,000  and  1  per  1000) ;  phenic  acid  (1  :  1000)  ;  quinine  and  cor- 
rosive sublimate  (1:1000).  In  experiments3  undertaken  by  C.  T.  Wil- 
liams in  1883,  with  respect  to  agents  which  check  the  development 
of  bacilli  most,  it  was  found  that  quinine  had  manifest  action  in  pre- 
venting their  development.  These  properties  and  this  power  are  not 
spoken  of,  and  were  not  probably  thought  of,  as  they  now  are,  by 
Bouchard  and  Gimbert.  They  are  of  the  opinion,  however,  that  creasote 
acts  locally  on  the  pulmonary  lesion  and  produces  marked  eifects  which 
are  also  beneficial.  Essentially,  they  believe  that  creasote  has  the  effect 
of  promoting  the  growth  of  fibrous  tissue  around  an  area  of  consolidated, 
or  broken-down  lung  structure.  Thus  it  is,  with  the  passage  of  time, 
that  the  cheesy  infiltrations  in  the  lungs  become  absorbed  little  by 
little,  as  the  softened  masses  (or  the  contents  of  large  cavities)  are 
expectorated  and  the  surrounding  walls  close  in  upon  a  relative  vacuum 
where  previously  necrosed  tissue  in  a  solid  or  liquid  form  was  largely 
present. 

As  will  be  seen  by  my  own  observations  in  a  few  cases  later  on,  I  am 
inclined  to  share  this  view  and  believe  in  its  exactness.4  In  regard  to 
it,  Jaccoud  writes  as  follows :  "  Creasote  seems  also  to  have  some  effect 
upon  the  fundamental  lesions  themselves,  and  to  promote  the  sclerotic 
change  by  means  of  which  recovery  is  found  to  occur  in  this  disease." 
(Loc.  cit.,  p.  156.)  Indeed,  Jaccoud  has  frequently  remarked,  after  the 
bronchitis  has  disappeared  and  stethoscopic  signs  of  a  pulmonary  lesion 
were  reduced  to  a  minimum,  that  two  or  three  months  later  there  was 
an  evident  and  secondary  diminution  in  the  extent  of  the  affected  area, 
and  bronchial  breathing  and  bronchophony  on  the  periphery  of  this 
area.  These  signs  accompanying  an  evident  improvement  in  the  general 
condition  seemed  to  indicate  evidently  a  sclerosis  around  the  area  of 
pulmonary  softening. 

1  According  to  Schill  and  Fischer,  who  mixed  tubercular  sputa  with  many  different  sub- 
stances and  afterward  inoculated  them  in  different  animals,  creasote  does  not  appear  to  have 
any  inhibitory  action  on  the  tubercular  virus,  (v.  Mittheilungen  aus  dem  K.  Gesundbeits- 
amte,  1884. 

-  On  transformation  of  true  or  infectious  tubercle  into  an  inert  foreign  body  under  the  influ- 
ence of  high  temperatures  and  various  reagents.  Arch,  de  Phys.,  1881,  p.  93;  Eevue  de  Med  . 
1882,  t.  ii.  p.  905  ;  1883,  t.  iii.  p.  209.— quoted  by  Beaumetz  in  New  Medications,  translated  by 
E.  P.  Hurd,  M.  D.— foot-note  on  p.  182. 

s  Proceedings  of  Royal  Society,  1884,  No.  221,  quoted  in  work  on  Pulmonary  Consumption, 
2d  ed.,  Philadelphia,  1887. 

*  This  view  would  appear  to  be  that,  also,  of  Spencer,  who,  in  speaking  of  the  antiseptic 
treatment  of  phthisis,  concludes  that  in  our  treatment  it  is  our  aim  to  promote  healing  of  the 
damaged  lung  tissue  by  means  of  fibroid  substitution.  (British  Medical  Journal,  January  28. 
188S.) 


C  R  E  A  S  O  T  E    IN     PHTHISIS    PULMONALIS.  13 

As  regards  the  anti-bacillary  effects  of  creasote  when  taken  internally, 
or  by  inhalation,  or  both  combined,  I  have  nothing  new  or  very  posi- 
tive to  offer.  On  two  occasions,  in  my  own  experience,  when  ordinary 
care  had  been  taken  by  a  good  examiner,  bacilli  which  previously  had 
been  present  in  considerable  numbers,  subsequent  to  treatment  had 
notably  decreased,  or  completely  disappeared.  In  other  cases  the  exam- 
inations made  did  not  permit  me  to  form  a  reliable  judgment  in  this 
regard.  As  to  whether  creasote  interferes  with  the  bacilli  locally,  or 
through  the  circulation  in  virtue  of  its  antiseptic  properties,  or  whether, 
in  addition  to  its  promotion  of  sclerosis,  it  merely  favors  general  nutri- 
tion whilst  acting  happily  upon  secondary,  though  important,  symptoms, 
I  am  not  prepared  absolutely  to  affirm.  I  would  add,  however,  that  I 
am  inclined  at  present  to  accept  the  latter  rather  than  the  former 
belief.  This  conviction  is  based  mainly  upon  what  seems  to  me  to  be 
a  fair  and  proper  interpretation  of  numerous  facts  observed  by  myself 
and  others  already  referred  to.  It  is  important  to  note,  however,  that  I 
am  now  decidedly  of  the  opinion  that  patients,  as  a  rule,  improve  more 
rapidly  and  surely  upon  the  conjoined  treatment  by  means  of  antiseptic 
inhalations  and  creasote  given  internally  than  they  do  upon  either 
treatment  by  itself.  I  have  attained  this  conviction  by  carefully  watch- 
ing the  effects  produced  when  one  or  other  of  these  methods  was  aban- 
doned for  a  time,  and  afterward  when  both  were  resumed  and  system- 
atically used.  It  is  probable,  therefore,  that  in  many  cases  the  frequent, 
or  prolonged,  topical  application  of  creasote  vapors  to  the  respiratory 
tract  in  a  considerable  area  is  of  undoubted  utility  and,  after  a  manner, 
not  very  different  from  what  I  have  previously  described. 

Another  fact  of  great  practical  importance  relates  to  the  purity  of 
the  drug  and  the  source  from  which  it  is  obtained.  For  the  information 
of  those  whose  attention  has  not  been  directed  closely  to  this  matter,  I 
would  state  that  in  New  York  City  (and  I  presume  elsewhere)  much 
of  the  creasote  which  is  dispensed  is  simply  crude  carbolic  acid,  obtained 
from  the  distillation*  of  coal-tar  oil,  and  commonly  called  "  commercial 
creasote."  It  has  neither  the  color,  the  odor,  nor  the  chemical  proper- 
ties of  wood  creasote,  or,  what  is  preferable,  of  the  creasote  which  is 
obtained  from  the  distillation  of  beechwood-tar.  I  am  glad  to  believe 
that  the  ordinary  dispenser,  in  making  this  pernicious  substitution,  is 
himself  a  victim  of  ignorance  and  not  of  knavery — at  least  so  far  as 
what  pertains  to  the  therapeutic  use  of  the  drug.  And  yet  in  moderate, 
or  large,  doses,  and  particularly  with  sensitive  patients,  there  is  a  very 
great  difference  in  the  effects  of  the  two  drugs.  The  one,  viz.,  carbolic 
acid,  may  prove  distinctly  injurious,  if  not  poisonous  ;  whereas  the  other, 
viz.,  wood  creasote,  when  judiciously  employed,  should  be  followed  by 
favorable  or  perhaps  negative  results,  but  rarely,  if  ever,  by  manifest 
bad  consequences.     I  am  credibly  informed  that  the  only  creasote  in  the 


14  CREASOTE    IN    PHTHISIS    PULMONALIS. 

market  to-day  which  responds  favorably  to  all,  or  most,  tests  of  abso- 
lute purity  is  that  of  T.  Morson  &  Son,  an  English  product,  which  is 
mentioned  on  page  497  of  the  United  States  Dispensatory,  and  that  of 
Merck,  a  German  product.  Of  the  two  products,  Morson's  is  the  one 
which  I  prescribe  and  believe  is  purest.  In  order  to  avoid  uncertainty, 
or  risk  in  prescribing,  it  is  essential  at  present  to  designate  definitely 
the  creasote  that  we  wish  to  employ  and  afterward  see  to  it  that  our 
prescription  is  taken  to  a  trustworthy  pharmacist. 

Through  inattention  to  the  foregoing  necessary  precautions,  ia  two 
instances  reported  to  me,  somewhat  poisonous  effects  were  produced  by 
the  internal  use  of  carbolic  acid,  when  it  was  intended  that  creasote 
should  be  taken. 

In  my  judgment,  whenever  creasote  is  prescribed  it  should  be  taken, 
at  least  at  the  commencement  of  treatment,  in  small  or  moderate  doses. 
These  doses  should  be  continued  a  long  while,  or  only  gradually  in- 
creased.1 If  an  attempt  be  made,  especially  at  first,  to  take  large  doses 
of  creasote,  in  the  majority  of  cases  stomachal  intolerance  will  soon 
follow,  and  we  shall  be  obliged  either  to  diminish  the  amount  prescribed 
or  lessen  the  frequency  of  doses,  or  abandon  the  treatment  altogether 
for  a  time.  My  experience  is  different  from  the  personal  experience  of  a 
Russian  physician,  Dr.  Bogdanovitch,  who  found  no  appreciable  benefit 
from  small  doses  (half  a  grain  four  or  five  times  a  day),  but  who, 
when  "he  began  to  take  creasote  in  gradually  increasing  large  doses, 
beginning  with  four  grains  a  day,  and  reaching  in  about  two  months  a 
daily  dose  of  forty-four  grains,  there  took  place  fairly  rapidly  an  un- 
mistakable and  permanent  improvement  in  his  symptoms."2  It  is,  also, 
different  from  the  reported  observations  of  Sommerbrodt  and  Guttmann, 
from  the  perusal  of  which  Bogdanovitch  took  his  inspiration. 

The  daily  amount  of  creasote  prescribed  by  me  for  adults,  in  private 
practice,  has  varied  usually  from  three  to  six  minims,  and  continued 
frequently  many  months  without  increase,  or  interruption,  or  any  evi- 
dence of  intolerance.  The  ordinary  dose  of  half  a  minim  is  repeated 
every  two  or  three  hours.  It  is  given  with  whiskey  and  glycerine, 
according  to  the  following  formula,3  which  is  that  of  Jaccoud,  the  sole 
difference  being  that  I  use  whiskey  where  Jaccoud  employs  cognac  or  rum  : 

R. — Creasoti  (beechwood) tt\,vj. 

Glycerine 3J. 

Spts.  frumenti •  .     |jij. — M. 

S. — As  directed. 

1  This  opinion  is  corroborated  by  that  of  Spencer  (British  Medical  Journal,  January  2S,  188S), 
who  says  that  the  influence  of  the  antiseptic  should  be  continuous  and  prolonged. 

2  British  Medical  Journal,  March  10,  1888. 

3  Whenever  the  mixture  is  taken  according  to  this  formula  no  addition  of  water  is  required, 
and  it  reminds  one,  by  its  smoky  odor  and  flavor,  of  slightly  sweetened  Scotch  whiskey. 


CREASOTE    IN    PHTHISIS    PULMONALIS.  15 

In  hospital  practice,  for  convenience  sake,  or  rather  so  as  to  give  the 
patient  a  sufficient  supply  of  medicine  to  last  until  his  next  visit  to  the 
hospital,  I  prescribe  teaspoonful  doses,  each  teaspoonful  containing  one 
minim  of  creasote,  and  to  it  are  added  two  teaspoonfuls  of  water.  This 
addition  is  made  to  prevent  irritation  of  the  throat  in  swallowing  the 
dose.  It  also  obviates  irritation  of  the  stomach  in  some  instances.  The 
dose  is  ordered  every  three  hours,  so  that  if  it  is  taken  with  absolute 
regularity  the  patient  gets  eight  minims  of  creasote  in  twenty-four  hours. 
This  is  rarely  the  case,  as,  owing  to  sleep  or  other  causes,  one  or  two 
doses  are  usually  omitted. 

The  formula  which  I  have  used  in  prescribing  creasote  is  a  very  good 
one,  as  in  it  the  creasote  is  perfectly  dissolved  and  sufficiently  diluted,  thus 
preventing  it  from  being  unpalatable  or  irritating.  The  perfect  solution 
of  creasote  and  its  large  dilution  are  both  strongly  insisted  upon  by 
Bouchard  and  Gimbert  in  their  original  article  as  being  essential  points 
in  rendering  it  acceptable  to  patients.  In  Jaccoud's  formula,  as  slightly 
modified  by  me,  we  obtain  the  well-known  beneficial  effects  of  whiskey 
and  glycerine  in  the  treatment  of  phthisis.  I  regard  it,  therefore,  as 
superior  to  the  following,  which  is  the  one  adopted  by  Frantzel  :J 

R. — Creasote n\,xv. 

Tinct.  gentian.     .......  "ixj. 

Spts.  vini  rect.     .         .         .         .         .        .        .  3vj. 

Vini  xeres q.  s.utfiant  §iv. 

S. — Jss  ter  die  ex  aqua. 

It  is  well  to  add  that  only  pure  whiskey  and  glycerine  should  be  em- 
ployed, and  as  the  latter  is  frequently  adulterated,  and  hence  injurious, 
I  would  indicate  Price's  or  Bowers's  glycerine  as  being  probably  the 
best. 

I  have  also  frequently  prescribed  creasote  in  gelatine  capsules  com- 
bined with  cod-liver  oil.  These  capsules  are  now  made  by  several  manu- 
facturers abroad,  and  may  be  readily  manufactured  in  the  United  States.2 
Each  capsule  contains  about  a  minim  of  creasote.  They  should  be  taken 
fifteen  or  twenty  minutes  after  meals.  At  other  times  they  are  apt  to 
cause  dyspeptic  symptoms.  Two  or  three  at  a  dose  mark  the  limit  of 
stomach  toleration  ordinarily,  and  in  only  one  or  two  instances  have  I 
been  able  to  increase  this  number  without  occasioning  digestive  disturb- 
ance. For  these  reasons  the  capsules  do  not  appear  to  me,  at  present, 
as  eligible  a  form  to  prescribe  creasote  as  the  mixture  of  creasote  with 
whiskey  and  glycerine. 

If  creasote  be  administered  in  cod-liver  oil,  the  amount  of  oil  must  be 
at  least  one  drachm  to  the  minim  of  creasote,  in  order  to  obtain  a  proper 

1  The  Year-book  of  Treatment  for  1887. 

2  Already  one  pharmacist  in  New  York,  to  my  knowledge,  makes  them. 


16 


CREASOTE    IN    PHTHISIS    PULMONALIS. 


dilution  of  this  drug.  Otherwise,  if  cod-liver  oil  be  indicated  for  a 
patient,  it  is  desirable  to  give  it  separately,  and  order  the  creasote  to  be 
taken  in  the  manner  first  advised.  This  I  have  done  in  several  instances, 
and  particularly  when,  despite  the  use  of  creasote,  with  complete  stomachal 
tolerance,  there  has  been  continual  loss  of  flesh. 

In  a  very  large  proportion  of  cases  of  pulmonary  phthisis  that  I  have 
treated  during  the  last  year  or  two  (and  in  every  one  of  the  cases  herein- 
after analyzed),  whilst  creasote  was  taken  internally,  antiseptic  inhala- 
tions were  also  used  by  means  of  the  perforated  zinc  inhaler.  As  a  rule, 
in  the  beginning,  the  inhaler  was  worn  during  fifteen  or  twenty  minutes 
every  three  hours,  and  from  ten  to  twenty  drops  of  the  inhaling  fluid 
were  poured  on  the  sponge  of  the  inhaler  at  least  three  times  in  twenty- 
four  hours.     The  inhaling  fluids  most  frequently  employed  by  me  were  : 

1.  A  combination  of  iodoform,  creasote,  eucalyptus,  chloroform,  alco- 
hol, and  ether,  seemingly  a  somewhat  formidable  mixture  in  view  of  its 
numerous  constituents,  but  a  very  rational  one  when  explained  in  detail. 

2.  Iodine,  creasote,  carbolic  acid,  and  alcohol. 

3.  Creasote  and  alcohol. 

The  first  one  of  these  inhalants  is  a  modification  of  one  taken  by  me 
from  Lauder  Brunton  ;  the  second  is  that  of  Dr.  Coghill,1  and,  according 
to  K.  Douglas  Powell,2  "  is  a  favorite  and  much  used  one ;"  the  third  is 
so  far  as  I  know,  my  own  combination.  The  following  are  the  precise 
formulae  : 


R. — Iodoform  i    .... 

. 

gr.  xxiv. 

Creasoti       .... 

"liv. 

01.  eucalypti 

Titviij. 

Chloroformi 

tr^xlviij.3 

Alcoholis  astheris 

aa  q.  s. 

3ss.— M. 

R  . — Tinct.  iodidi  retherahs, 

Acidi  carbolici     . 

aa 

3ij. 

3j- 

Sp.  vini  rect. 

.    ad. 

Sj.-M. 

R. — Creasoti        .... 

3j. 

Alcoholis     .... 

.     ad. 

gss.— M. 

I  desire  now  to  direct  attention  to  the  tabulated  statement  of  the 
results  obtained  by  me  from  the  creasote  treatment  of  pulmonary 
phthisis. 


1  Antiseptic  Inhalations  in  Pulmonary  Affections.  By  J.  St.  Clair  Coghill,  M.D.,  Brit.  Med. 
Journal,  1881,  vol.  i.  p.  841. 

2  Loc.  cit.,  p.  308. 

3  The  chloroform  in  this  formula  was  originally  added  by  me  on  account  of  its  value  as  a 
preventive  of  cough.  I  am  glad  to  And  that,  according  to  Salkovvski  (Deutsche  med.  Wochen- 
schrift,  April  19, 1888),  it  is  also  most  available,  from  its  volatility,  amongst  the  ethylic  chlorine 
compounds,  as  a  respiratory  antiseptic. 


CREASOTE    IN    PHTHISIS    PULMONALIS.  17 

The  total  number  of  cases  which  have  taken  creasote  mixture  and 
used  creasote  inhalations  (simple  or  compound),  to  which  I  have  refer- 
ence, are:  At  the  New  York  Hospital,  out-patient  department,  142; 
in  private  practice,  19.  Besides,  I  have  an  interesting  letter  from  my 
late  house  physician,  at  St.  Luke's  Hospital,  Dr.  Charles  II.  Collins, 
who,  at  my  request,  looked  carefully  over  the  records  of  that  institution 
and  found  that  during  the  last  two  years  about  150  cases  of  phthi-i- 
pulmonalis  have  there  been  put  on  the  creasote  treatment,  and  a  large 
percentage  of  these  cases  he  has  been  able  to  watch.  The  points  of 
interest  observed  by  Dr.  Collins,  and  the  reflections  made  by  him  in  his 
letter  to  me  I  will  reproduce,  after  giving  an  analysis  of  my  own  obser- 
vations— recorded  by  myself  with  some  care. 

Of  the  total  number  of  143  cases  seen  at  the  New  York  Hospital, 
there  were  51  cases  of  pulmonary  phthisis  at  the  first  stage  of  the  dis- 
ease; 18  cases  at  the  second  stage,  18  cases  at  the  third  stage;  there 
were  also  4  cases  of  laryngeal  phthisis,  1  case  of  fibroid  phthisis,  and  1 
case  of  acute  phthisis.  The  total  number  of  cases,  therefore,  in  which 
the  diagnosis  is  mentioned  of  the  stage  and  nature  of  the  disease,  is 
93 — leaving  50  cases  of  pulmonary  phthisis  in  which  the  stage  of  the 
disease  is  not  mentioned.  Of  the  whole  number  of  cases  seen  at  the 
out- door  department  of  the  New  York  Hospital,  54  were  females,  89 
were  males. 

Of  the  93  cases  mentioned,  there  are  47  cases  in  which  some  notes 
were  made  as  to  the  effect  of  treatment,  of  more  or  less  value.  Of  these 
47  cases,  I  have  arranged  in  tabular  form  such  data  as  seemed  to  me  to 
be  of  any  interest.  I  have  also  done  a  similar  work  in  regard  to  my  19 
private  cases.  From  these  tables  I  shall  now  proceed  to  take  such  facts 
as  result  from  their  study. 

The  duration  of  time  during  which  these  cases  were  treated  varied 
from  one  week  to  two  years  eleven  and  a  half  months.  Of  these  66 
cases,  45  were  males  and  21  females.  Thirty-seven  cases  were  affected 
with  the  first  stage  in  a  manifest  manner,  as  shown  by  the  physical  signs 
and  the  rational  symptoms ;  in  3  cases  the  physical  evidences  of  disease 
were  doubtful  or  negative,  although  the  rational  symptoms  pointed  plainly 
to  beginning  phthisis ;  in  6  cases  there  was  found  an  evident  second 
stage  of  phthisis  ;  in  1  it  was  a  question  whether  the  case  had  advanced 
so  far  as  the  second  stage ;  in  11  cases  the  disease  had  attained  the  third 
stage ;  in  the  remaining  cases  the  diagnosis  of  the  stage  of  disease  is  not 
recorded. 

In  cases  of  the  first  stages  of  the  disease,  24  had  their  cough  improved, 
sometimes  very  much,  sometimes  only  a  little;  in  3  cases  the  cough  did 
not  improve;  in  10  cases  the  cough  was  cured.  In  several  cases  in  which 
the  cough  was  improved,  the  sleep  was  quieter,  and  previous  insomnia 
evidently  depended  largely  upon  cough  and  expectoration  ;    in  a  few 


18  CREASOTE    IN    PHTHISIS    PULM  ON"  ALIS. 

instances,  even  though  the  cough  improved,  the  sleeplessness  did  not 
improve,  and  evidently  was  independent  of  the  cough.  In  those  in- 
stances in  which  the  cough  is  stated  as  being  cured,  I  cannot  say  in  all 
of  them  how  long  the  cure  lasted  ;  in  some,  I  know,  the  cough  returned, 
but  was  again  cured  by  the  use  of  creasote  in  mixture  and  as  an  inhala- 
tion. In  many  cases  at  different  stages  (first,  second,  and  third) — 17  in 
all — no  mention  is  made  of  the  effect  of  creasote  on  the  cough.  In 
some  of  these  instances  it  is  possible  that  the  question  was  not  asked  ;  in 
many  of  them  it  is  probable  that  no  mention  is  made,  because  the  cough 
remained  stationary.  What  I  say  here  for  the  cough,  I  should  be 
obliged  to  repeat  for  other  symptoms,  and  I  would,  therefore,  offer  this 
as  an  explanation  where  my  silence  shall  point  to  it,  without  my  weary- 
ing you  by  similar  repetition. 

In  3  cases  of  phthisis  at  the  second  stage,  cough  improved  either 
slightly  or  very  much.  In  the  other  cases  it  remained  stationary ;  in 
no  case  did  it  increase.  In  6  cases  of  phthisis  at  the  third  stage,  the 
cough  improved  notably  in  4  ;  in  1  the  improvement  was  very  great ; 
in  1,  instead  of  improving,  it  became  worse. 

As  regards  night-sweats  at  the  first  stage,  8  cases  were  cured  ;  4  im- 
proved ;  3  remained  stationary ;  in  1  case  they  increased  ;  in  6  cases  the 
patients  never  suffered  from  them ;  in  15  cases  no  mention  is  made  of 
this  symptom.  At  the  second  stage,  1  case  was  cured,  1  remained 
stationary.  In  a  doubtful  case  of  second  stage,  there  was  great  im- 
provement in  1  instance.  In  4  cases  no  mention  is  made.  At  the  third 
stage,  1  case  was  cured,  2  improved  (1  greatly),  1  patient  never  had 
night-sweats;  in  7  there  was  no  mention  of  them. 

With  respect  to  dyspnoea  at  the  first  stage,  15  cases  were  improved, 
4  cured,  1  case  remained  stationary,  1  case  never  had  dyspnoea;  there  is 
no  mention  in  regard  to  this  symptom  in  the  other  cases.  At  the  second 
stage,  1  case  was  cured,  2  cases  improved,  1  case  remained  stationary  ; 
in  2  cases  no  mention  is  made.  At  the  third  stage,  5  cases  improved ; 
in  6  cases  no  mention  is  made. 

The  sputa  at  the  first  stage  diminished  in  quantity,  and  improved 
notably  in  appearance  in  18  cases;  in  5  cases  the  sputa  disappeared  ; 
in  3  cases  there  was  no  diminution  in  amount  of  sputa;  in  1  case  the 
sputa  increased  in  quantity;  in  2  cases,  in  which  bacilli  had  been  found 
in  the  sputa,  later  on  they  could  not  be  found.  In  3  cases  the  bacilli 
were  looked  for  merely  to  verify  the  diagnosis,  and  they  were  not  looked 
for  later  on  to  see  if  they  had  disappeared. 

Three  times  the  sputa  did  not  change  in  appearance  or  quantity,  but 
were  raised  more  easily.  The  changes  in  appearance  of  the  sputa  were 
often  quite  remarkable,  and  from  green  and  yellow  they  became  white 
and  frothy ;  less  tenacious,  less  thick.  When  the  sputa  diminished  in 
quantity  and  were  less  viscid,  cough  decreased  and  sleep  often  improved. 


CREASOTE    IN    PHTHISIS     PULMONALIS.  19 

At  the  second  stage,  the  sputa  diminished  notably  in  quantity  in  leases; 
in  1  case,  although  they  did  not  diminish  much  in  quantity,  they  changed 
their  appearance  for  the  better  and  became  less  thick  and  tenacious. 
At  the  third  stage  the  sputa  diminished  much  in  quantity  in  4  cases. 

The  appetite  was  improved  in  17  cases  at  the  first  stage  ;  it  remained 
stationary  in  3  cases  ;  in  no  case  did  it  notably  diminish.  It  improved 
in  2  cases  at  the  second  stage  ;  in  1  case  it  diminished.  In  4  cases  at 
the  third  stage,  appetite  increased.  In  3  cases  at  the  second  stage,  and 
in  7  at  the  third  stage,  there  is  no  mention  of  the  effect  on  appetite. 

In  2  cases  dyspepsia  was  occasioned  by  creasote ;  in  one  of  these  cases 
the  mixture  was  continued,  and  the  dyspepsia  soon  improved  ;  in  the 
other  case  capsules  of  cod- liver  oil  and  creasote  were  given,  and  had  to 
be  abandoned  altogether. 

In  2  cases  nausea  and  gastralgia  were  evidently  caused  by  the  creasote 
mixture,  which  was  stopped  for  a  while.  In  3  cases  the  medicine  caused 
constipation,  in  1  case  the  constipation  remained  the  same  ;  in  3  cases 
the  constipation  was  cured  by  creasote  mixture. 

In  2  cases  diarrhoea  was  brought  on  ;  in  1  case  there  was  considerable 
pain  in  the  bowels;  in  3  cases  there  .was  no  effect  on  the  bowels  at  all; 
in  2  cases  the  bowels  became  more  regular ;  previously  there  had  been 
alternate  attacks  of  constipation  and  diarrhoea. 

The  effect  on  weight  was  very  notable  in  many  instances.  In  18  cases 
at  the  first  stage,  there  was  increase  of  weight,  the  amount  of  increase 
ranging  from  one-half  pound  to  twenty-five  pounds.  Two,  three,  and 
four  pounds'  increase  was  quite  common.  One  patient  gained  three 
pounds  in  six  weeks'  treatment.  In  4  cases  weight  remained  stationary. 
In  3  cases  weight  was  lost,  in  1  of  these  in  moderate  amount  (about 
two  and  one-half  pounds),  due  to  an  acute  attack.  Previous  to  this 
attack,  weight  had  been  stationary.  In  2  cases  there  was  a  loss  of  five 
pounds ;  in  1  of  them  four  pounds  were  subsequently  regained  by  three 
weeks'  use  of  malt  and  cod-liver  oil.  At  the  second  stage,  in  2  cases 
there  was  some  loss  of  weight;  in  1  the  weight  remained  stationary; 
in  3  cases  there  was  no  mention  of  it.  At  the  third  stage,  there  was 
increase  of  weight  in  2  cases,  loss  in  1,  stationary  in  1,  no  mention  in  7. 

In  a  large  proportion  of  cases — 46  in  all — no  mention  is  made  of 
haemoptysis.  In  11  cases  at  the  first  stage,  no  haemoptysis  occurred 
during  treatment;  in  3  of  these  cases  haemoptysis  had  occurred  pre- 
viously, small  or  large  in  amount.  In  4  cases  a  slight  or  very  moderate 
spitting  of  blood  occurred,  but  in  all  these  cases  one  or  several  hemor- 
rhages from  the  lungs  had  taken  place  before  the  creasote  treatment  was 
begun.  In  1  case  at  the  second  stage,  hemorrhage  occurred  during 
treatment ;  but  in  this  case  several  hemorrhages  took  place  before  treat- 
ment was  instituted.  In  5  cases  no  mention  is  made  of  hemorrhage. 
In  4  cases  at  the  third  stage,  no  hemorrhage  occurred  either  during,  or 


20  CREASOTE    IN    PHTHISIS    PULMONALIS. 

before  treatment  with  creasote.  In  7  cases  no  mention  is  made  of  it. 
It  seems  probable,  therefore,  from  the  foregoing  statements,  that  whilst 
creasote  may  not,  except  to  a  very  limited  extent,  control  pulmonary 
hemorrhage,  it  does  not  promote  or  occasion  it,  and  may,  therefore,  be 
given  with  perfect  safety  to  those  patients  who  are  liable  to  these  re- 
currences, and,  indeed,  during  the  period  they  actually  take  place. 

As  regards  elevation  of  temperature,  no  record  was  made  in  41  cases. 
In  the  others,  as  well  as  could  be  determined,  the  following  is  probably 
a  correct  statement:  In  7  cases  fever  was  cured  under  creasote  treat- 
ment, viz.,  it  disappeared  and  did  not  return  during  the  time  the  patient 
was  under  observation.  In  9  cases  fever  was  notably  lessened.  In  1 
case  of  these  9,  the  fever  returned  for  a  time  when  the  patient  had  an 
acute  exacerbation  of  the  disease,  which  occurred  several  times  during 
many  months,  and  did  not  always  appear  to  be  occasioned  by  impru- 
dence, or  cold,  but  was  rather  the  natural  outcome  of  the  disease. 
In  8  cases,  so  far  as  could  be  observed,  no  perceptible  effect  was  pro- 
duced on  the  fever,  and  it  remained  about  stationary.  In  only  1  case 
did  the  temperature  rise  whilst  the  patient  was  under  treatment,  and 
then  only  to  a  slight  degree. 

It  is  fair  to  assume  that  in  creasote.  we  have,  in  the  treatment  of 
phthisis,  an  antithermic  agent  of  no  mean  value. 

In  35  cases  there  was  no  mention  of  the  effect  of  the  treatment  on 
the  strength  of  the  patients.  In  26  cases  there  was  manifest  improve- 
ment in  strength.  In  6  of  these  the  strength  is  spoken  of  as  "  returned  " 
or  "  regained."  In  3,  as  greatly  improved  ;  in  17,  as  notably  improved. 
In  1  case  strength  remained  stationary;  in  4  cases  strength  diminished. 

Pains  in  chest  were  cured  8  times;  improved,  13;  stationary,  2; 
none  in  one  instance.     In  42  cases  no  mention  is  made. 

Pains  in  throat  were  cured  in  6  cases,  improved  in  7,  made  worse  in 
3,  remained  stationary  in  2.  In  five  cases  patient  never  suffered  from  pain 
in  the  throat ;  in  43  cases  no  mention  is  made.  In  1  case  of  cure  it 
was  attributable  to  the  inhalations.  In  3  cases  in  which  the  pains  in 
the  throat  improved,  the  previous  hoarseness  diminished,  more  or  less,  or 
disappeared  entirely. 

In  the  3  cases  in  which  the  pains  in  the  throat  became  worse,  they 
were  thus  caused  by  the  local  irritating  effects  of  the  mixture.  In  one 
instance  the  voice  became  weaker  and  more  hoarse. 

The  pulse  is  noted  as  being  less  frequent  and  stronger  in  6  cases  ;  in  2 
as  normal ;  in  2  as  showing  no  apparent  change  and  remaining  frequent. 
In  the  other  instances  no  mention  is  made. 

Generally  speaking,  there  was  no  change  in  the  appearance  or  amount 
of  urine  passed.  On  only  one  occasion  did  it  apparently  increase  con- 
siderably in  quantity,  owing  to  the  use  of  creasote  ;  on  another  it  became 
clearer,    where  previously    it  had    contained    considerable    deposits    of 


CREASOTE    IN     PHTHISIS    PULMONALIS.  21 

urates;  in  a  third  instance  the  urine  became  more  turbid.  On  many 
occasions  it  was  tested  for  albumin;  either  none  was  found,  or  the  amount 
previously  existing  in  the  urine  remained  the  same.  No  casts  were 
observed,  in  repeated  examinations,  which  could  be  ascribed  to  the  use 
of  creasote,  nor  did  any  pronounced  dark  discoloration  occur,  such  as 
may  follow  the  internal  use  of  coal-tar  creasote.  In  no  instance  could  I 
detect  the  odor  of  creasote  in  the  urine,  and  in  only  one  did  ordinary 
tests  reveal  its  presence.  This  was  a  case  of  acute  phthisis  in  a  young 
woman  who  was  taking  at  the  time  sixteen  minims  of  creasote  daily  and 
who  was,  also,  making  frequent  use  of  creasote  inhalations. 

As  regards  physical  signs,  I  have  only  2  cases  at  the  first  stage,  to 
report  of  complete  disappearance  of  every  evidence  of  morbid  condi- 
tion in  the  lungs.  In  two  other  instances  the  signs  improved  so  much 
that  it  required  the  strictest  construction  not  to  pronounce  them  cured. 
In  10  cases  at  first,  second,  and  third  stages,  there  was  slight  or  decided 
improvement  in  the  physical  signs  revealed  by  careful  examinations  of 
the  chest. 

This  improvement  consisted  in  fewer  moist  rales  heard  at  the  apices, 
in  diminished  area  of  dulness,  in  diminution  of  thoracic  vibrations,  of 
resonance  of  the  voice,  in  softened,  less  prolonged  expiratory  murmur, 
which  was  also  of  lower  pitch.  Among  the  cases  which  I  have  observed, 
there  have  been,  in  my  opinion,  at  least  four  apparent  cures,  if  due  con- 
sideration be  given  to  the  effects  produced  on  both  signs  and  symptoms 
of  pulmonary  phthisis.1 

Dr.  Charles  F.  Collins's  report,  dated  St.  Luke's  Hospital,  May  30, 
1888,  reads  as  follows  : 

"  In  regard  to  the  creasote  treatment  in  phthisis  pulmonalis  in  hos- 
pital cases,  I  have  gone  through  all  the  records  since  the  treatment  was 
first  begun.  The  notes  in  the  cases,  though  accurate,  are  not  complete 
enough  to  enable  me  to  make  satisfactory  tables  and  to  draw  positive 
conclusions  concerning  special  points.  Then,  also,  the  previous  condi- 
tion of  most  of  the  hospital  cases  is  often  very  bad  in  respect  to  hygienic 
surroundings,  often  suffering  from  want  of  food  and  rest,  so  that  after 
admission  to  the  hospital  when  improvement  takes  place  it  is  sometimes 
difficult  to  isolate  the  special  value  of  treatment  per  se.  Then,  too, 
there  are  many  cases  admitted  in  the  last  stages  and  the  condition  often 
without  hope,  so  that  any  results  from  treatment  are  not  looked  for  ;  to 
keep  the  patient  comfortable  is  the  only  attempt  by  way  of  treatment 
that  is  available.  It  is  also  in  hospital  cases  almost  impossible  to  avoid 
treating  specific  symptoms,  such  as  night-sweats,  wakefulness,  diar- 
rhoea, etc. 


1  The  cases  will  be  found  reported  in  full  in  the  Transactions  of  the  Association  of  American 
Physicians  for  1888. 


22  CREASOTE    IN    PHTHISIS    PULMONALIS. 

"  During  the  last  two  years  about  a  hundred  and  fifty  cases  of 
phthisis  have  been  put  on  the  creasote  treatment,  and  a  large  percentage 
of  these  I  have  been  able  to  watch,  and  the  following  points  may  prove 
of  value.  It  never  has  been  discovered  that  the  drug  in  any  way  caused 
gastric  distress  or  intestinal  symptoms.  It  is  pleasant  to  take  and,  in 
the  formula  you  introduced,  patients  often  ask  for  it  when  leaving  and 
take  it  for  a  length  of  time,  and  I  have  never  known  a  patient  to  dislike 
the  mixture. 

"  As  to  urinary  and  kidney  symptoms  I  would  add  the  following: 
There  has  never  been  any  perceptible  change  in  the  quantity  during 
the  twenty-four  hours,  and  repeated  examinations  chemically  of  the 
urine  of  patients  on  creasote  have  failed  to  reveal  any  changes ;  as  far 
as  I  can  judge,  have  not  known  it  to  cause  albumin  even  though  con- 
tinued for  months,  and  many  cases  suffering  from  renal  complications 
when  admitted  to  the  hospital  show  no  signs  of  an  increase  of  their 
trouble  in  regard  to  urine  when  put  on  creasote  treatment. 

"  In  general,  I  would  like  to  add  that  this  mode  of  treatment,  the  in- 
halations as  well  as  internal  administrations,  seems  to  give  better  results 
and  be  more  available  than  any  mode  of  treatment  we  have  followed 
out.  Many  cases  leaving  the  hospital  have  asked  for  the  prescription, 
and  in  cases  which  I  have  been  able  to  follow  and  which  have  con- 
scientiously carried  out  treatment,  as  far  as  can  be  judged,  there  seemed 
to  be  a  lasting  benefit  and  continued  improvement. 

"It  is  a  matter  of  considerable  regret  that  I  cannot  give  you  records 
of  a  number  of  special  cases,  but  on  account  of  the  conditions  above 
mentioned,  truthful  records  of  hospital  patients  suffering  from  diseases 
of  this  character  are  always  subject  to  many  errors." 

In  this  place,  and  before  giving  my  conclusions  to  this  paper,  I  will 
add  a  few  words  which  I  believe  are  important  to  bear  in  mind.  We 
all  know  how  readily  one  may  be  deceived  by  tabular  statements, 
or,  indeed,  occasionally  by  reported  cases.  It  is  so  easy  to  prove  too 
much !  Whilst  error,  however,  often  arises  from  the  over-valuation  o± 
a  particular  drug,  it  is  possible  to  underestimate  the  utility  of  a  real 
addition  to  our  curative  means  in  this  line,  when  judged  after  a  similar 
manner.  Therefore  it  is  that  final  remarks  or  reflections,  more  or  less 
in  the  form  of  conclusions,  must  frequently  be  added,  so  that  a  correct 
opinion  should  be  formed  of  what  a  writer  really  believes. 

I  am  convinced,  in  view  of  what  I  have  seen,  the  proofs  of  which  I 
have  stated,  and  notwithstanding  their  imperfect  character  in  many 
particulars,  that  we  have  in  beech  wood  creasote  a  remedy  of  great  value 
in  the  treatment  of  pulmonary  phthisis,  particularly  during  the  first 
stage.  Not  only  does  it  lessen  or  cure  cough,  diminish,  favorably  change 
and  occasionally  stop  sputa,  relieve  dyspnoea  in  very  many  instances ; 
it  also  often    increases  appetite,  promotes  nutrition,  and  arrests  night- 


CREASOTE    IN     PHTHISIS    PULMONALIS.  23 

sweats.  It  does  not  occasion  haemoptysis,  and  rarely  causes  disturbance 
of  the  stomach  or  bowels,  except  in  cases  in  which  it  is  given  in  too 
large  doses. 

There  is  a  fair  amount  of  evidence  to  show  that  by  its  long-continued, 
judicious  use,  it  may  and  will  modify  favorably  the  local  changes  in 
pulmonary  phthisis,  and  how  it  does  this  I  have  pointed  out  previously, 
as  far  as  I  was  able.  Whether  or  not  it  has  any  direct  anti  bacillary 
effect  when  given  internally,  or  by  inhalation,  or  both  combined  (the 
latter  method  being,  in  my  judgment,  the  most  efficient  one;,  remains  as 
yet  to  be  determined  in  a  more  accurate  manner.  It  is  certainly  an  un- 
objectionable medicament  from  any  point  of  view.  It  is  easy  of  adminis- 
tration ;  it  is  adapted  to  the  majority  of  sufferers  from  pulmonary  phthisis 
everywhere ;  it  may  be  used  with  some  advantage  at  all  stages  of  this 
disease,  even  the  most  advanced,  and  in  my  experienced  has  proven  itself 
superior  to  any  other  medicinal  treatment  with  which  I  am  familiar. 

That  in  all  cases  the  nutrition  is  the  cardinal  factor  to  be  always  kept 
in  view  in  the  treatment  of  pulmonary  phthisis,  no  matter  what  method 
or  course  be  followed,  is,  I  believe,  as  true  today  as  it  always  has  been 
from  the  clinical  standpoint,  and  without  regard  to  the  passing  theories 
which  may  be  adopted  in  regard  to  the  precise  role  or  influence  of  mi- 
crobes in  the  pulmonary  structures.  The  words  of  Dujardin-Beaumetz1 
seem,  in  this  connection,  of  much  value  : 

"There  do  not  exist  several  medications  of  phthisis ;  there  is  but  one,  that 
which  addresses  itself  to  the  nutrition ;  the  others  are  only  adjunct  methods, 
which  become  dangerous  if  they  succeed  in  affecting  unfavorably  a  single 
day,  a  single  instance,  the  digestive  functions." 

Or  those  other  words  of  E.  L.  Trudeau  :2 

"  It  should  be  kept  in  view  that  so  long  as  the  tissues  present  a  favorable 
nidus  for  the  development  of  the  bacilli,  the  destruction  of  a  portion  of  them, 
if  this  should  be  found  feasible,  would  not  necessarily  eradicate  the  disease." 

To  the  end  of  altering  those  chemical  and  vital  changes  in  the  organism 
which  allow  of  the  growth  of  the  microbe,  "  thus  far  those  conditions 
which  promote  bodily  vigor  have  alone  been  found  effectual." 

1  Lemons  de  Clinique  Therapeutique,  t.  2,  p.  647.  -  Medical  News,  May  5,  1S88,  p.  490. 


ON  THE  COURSE  AND  TREATMENT  OF  CERTAIN 

URJEMIC  SYMPTOMS. 


In  beginning  my  paper  I  wish  to  say  that  I  ana  in  doubt  as  to  the 
title  of  it.  In  some  respects  I  would  prefer  to  use  the  designation 
"  symptoms  of  renal  insufficiency,  or  inadequacy  "  rather  than  "  ursemic 
symptoms."  I  make  this  statement  because  uraemia  does  not  satisfac- 
torily express,  as  we  all  know,  our  belief  to  day  in  regard  to  the  precise 
etiology  of  many  cases  in  which  the  kidneys  are  no  doubt  at  fault  pri- 
marily or  secondarily.  If,  however,  I  employ  the  designation  renal 
insufficiency,  I  feel  that  exception  may  be  taken  to  the  title,  as  I  shall 
speak  of  cases  in  which  the  kidney  is  surely  affected  with  well-defined 
structural  changes,  and  the  term  uraemia,  as  it  is  generally  received, 
implies  this  belief  in  the  majority  of  instances. 

In  my  daily  routine,  especially  of  private  practice,  I  meet  with  cases 
of  the  kind  I  shall  at  first  try  to  describe,  and  with  which  doubtless  you 
are  more  or  less  familiar.  The  patients  to  whom  I  refer  are,  as  a  rule, 
what  are  called  healthy,  i.  e.,  they  have  no  distinctly  marked  organic 
changes  which  are  discoverable  in  their  different  organs ;  or  these 
changes  are  so  slight  in  amount  that  I  cannot  fairly  attribute  major  im- 
portance to  the  state  of  one  organ  as  compared  with  others,  without  the 
most  careful  analysis  of  all  the  conditions  involved.  Such  patients, 
however,  have  habitually  some  little  bodily  annoyances  which  fret 
them  more  or  less,  and  from  which  they  desire  to  be  relieved,  and  they 
naturally  seek,  sooner  or  later,  the  physician's  care.  In  regarding  these 
patients  at  present  I  am  satisfied  that  many  of  them  suffer  primarily 
from  slight  renal  disorder.  This  affection  of  the  kidneys,  mainly  func- 
tional, is  at  times  more  pronounced,  and  occasions  symptoms  which 
hitherto  we  have  considered  under  the  term  ursemic. 

In  the  mildest  forms  of  the  trouble,  I  believe  renal  insufficiency  is  a 
more  appropriate  term,  particularly  if  we  limit  its  proper  significance. 
I  am  aware  that  the  term  itself  is  frequently  employed  in  descriptions  of 
uraemia,  although  I  have  not  found  an  article  or  chapter  in  which  the 
epithet  was  used  as  the  title  of  a  recognized  condition.  By  adopting 
this  name  with  this  purpose,  we  shall  be  able  hereafter  to  employ  it  to 
cover  a  definite  series  of  symptoms,  which,  in  my  judgment,  are  not 
otherwise  properly  designated. 


TREATMENT    OF     UREMIC    SYMPTOMS.  25 

I  will  now  narrate  a  few  cases  in  my  later  professional  experience 
which  shall  serve  as  a  text  to  explain  my  position. 

Case  I. — A  lawyer ;  widower  ;  fifty-five  years  old ;  a  man  of  large 
frame,  who  has  enjoyed  excellent  health.  In  the  winter  months  he 
suffers  from  nasal  obstruction  and  formation  of  excess  of  mucus  in  the 
naso-pharyngeal  space,  which  he  relieves  by  efforts  of  hawking.  Patient 
has  a  somewhat  constipated  habit,  and  his  urine  is  often  higher  colored 
than  is  normal.  Frequently,  however,  the  density  and  color  are  normal. 
It  contains  at  these  times  no  abnormal  ingredient.  Whenever  the  den- 
sity increases  and  the  color  is  darker,  there  is  a  heavy  deposit  of  pink 
urates;  but  there  is  no  albumin,  no  sugar,  and  rarely,  if  ever,  any  casts. 
The  quantity  of  urine  voided,  as  a  rule,  approximates  the  normal.  When 
the  color  becomes  dark  and  the  density  increases,  the  quantity  dimin- 
ishes, but  not  usually  to  any  great  extent  The  patient  under  the  latter 
circumstances  suffers  from  general  neuralgic  manifestations,  mild  in  form, 
and  which  rapidly  disappear  under  judicious  medical  management. 
Appetite  is  excellent ;  no  dyspeptic  symptoms  ordinarily  ;  lives  well, 
but  commits  no  excesses.  Very  moderate  in  the  use  of  wines  or  distilled 
liquors.  No  attacks  of  rheumatism  or  gout.  He  finds  himself  much 
better  in  health  when  he  eschews  sweets  and  butchers'  meat;  feels  more 
buoyant  and  in  better  shape  when  his  meals  consist  mainly  of  vegetables, 
and  particularly  rice,  and  when  he  eats  white  meats,  fresh  fish,  and  eggs. 
On  several  occasions,  I  have  attended  him  professionally,  when,  without 
knowledge  of  the  precise  cause  of  his  attack,  he  has  had  sneezing  and 
running  of  the  nose ;  little  or  no  fever ;  slight  cough  ;  no  evidences  of 
stomachal  derangement,  and  yet  he  was  evidently  torpid  or  sluggish 
and  complained  of  marked  drowsiness.  The  urine  at  these  times  was 
dark-colored  and  loaded  with  urates.  A  mercurial,  followed  by  a  brisk 
saline  purge,  on  two  successive  days,  rest  in  the  house,  the  free  use  of 
natural  Vichy  water,  and  very  light  diet,  cured  these  manifestations  of 
disordered  function,  and  in  a  few  days  he  resumed  his  occupation  and 
was  as  well  as  previously. 

Case  II. — A  broker  ;  forty-two  years  old  ;  married  ;  thin  and  spare  ; 
of  an  energetic,  resolute  character ;  states  that  several  years  ago  he 
passed  a  small  mulberry  calculus,  but  previous  and  subsequent  to  this 
attack  has  had  no  disease  for  many  years.  His  urine  is  habitually  some- 
what high-colored,  otherwise  normal ;  his  intestinal  digestion  is  imper- 
fect ;  he  is  somewhat  constipated  at  times ;  again  he  has  two  move- 
ments in  the  twenty-four  hours,  which  are  formed,  but  not  as  large  as 
would  seem  to  be  healthful,  due  regard  being  had  to  the  amount  he 
eats.  His  diet  is  varied,  abundant,  but  not  excessive.  He  drinks  wine 
moderately  ;  he  smokes,  but  not  to  excess.  He  is  often  annoyed  with 
vague  pains  in  his  abdomen  which  extend  into  the  lumbar  region. 
These  pains  are  not  severe  as  a  rule,  and  usually  are  merely  uncomfort- 
able sensations.  His  abdomen  is  perhaps  slightly  distended  and  tense, 
but  he  is  scarcely  annoyed  with  flatus.  The  epigastrium  is  somewhat 
tender  on  pressure,  as  also,  occasionally,  are  other  regions  of  the  ab- 
dominal cavity.  There  is  no  manifest  stomachal  dyspepsia.  The  vague 
abdominal  pains  come  at  irregular  intervals  during  the  day,  last  a  vari- 
able time,  and  disappear  quite  suddenly.  Patient  is  rendered  irritable 
and  somewhat  morbid  by  reason  of  his  abdominal  condition.  He 
is  also  conscious  of  a  slight  laryngeal  irritation  which  obliges  him  to  ex- 

3 


26  TREATMENT    OF    UREMIC    SYMPTOMS. 

pectorate  a  small  quantity  of  viscid  phlegm  occasionally.  His  tongue  is 
broad,  slightly  coated  on  the  dorsum  ;  his  skin  is  sallow  ;  his  liver  is  not 
enlarged.  Strict  regulation  of  the  diet,  as  in  the  previous  case,  the 
regular  use  of  euonymin,  podophyllin,  or  cascara,  persistent  drinking  of 
Giesshubler  or  Vals  water,  have  ameliorated  but  not  cured  my  patient. 
Latterly,  I  have  prescribed  salicylate  of  bismuth  in  addition  to  what 
precedes,  with  the  hope  that  intestinal  antisepsis  thus  produced  would  be 
effective  in  controlling  the  symptoms  of  functional  disturbance  which  I 
have  outlined  and  which  I  have  been  led  to  believe  were  caused  by  renal 
insufficiency. 

Case  III. —  Only  a  few  weeks  sincel  was  called  suddenly  to  see  a  near 
and  dear  relative  who  had  been  attacked  with  alarming  symptoms  of 
obstinate  nausea  and  vomiting,  marked  cardiac  weakness,  and  with  but 
few  or  no  evidences  in  the  urine,  except  just  before  the  fatal  termina- 
tion, of  renal  complication :  at  this  time  a  small  quantity  of  albumin 
and  hyaline  casts  was  discovered.  The  patient  was  fifty-eight  years 
old,  the  manager  of  important  railroad  lines.  He  had  always  been  re- 
markably strong  and  active.  Owing  to  great  irregularity  of  meals  and 
the  immoderate  use  of  tobacco  and  whiskey,  he  was  a  sufferer  frequently 
from  flatulent  dyspepsia,  which  he  relieved  with  large  doses  of  bicar- 
bonate of  soda.  Some  weeks  previous  to  his  death  he  had  an  attack  of 
pneumonia,  moderate  in  severity.  From  this  attack  he  had  nearly  re- 
covered, when,  by  reason  of  over-fatigue,  anxiety,  and  exposure,  a  mild 
invasion  of  acute  articular  rheumatism  developed.  The  fever  had  dis- 
appeared and  he  was  almost  convalescent  from  this  disease,  when,  owing 
to  the  immediate  effects  of  a  cold  bath,  the  final  symptoms  occurred, 
and  were  regarded  by  the  family  physician  as  evidences  of  Bright's  dis- 
ease. When  I  saw  the  patient  I  thought  the  kidneys  were  congested, 
but  secondarily  to  the  action  of  a  weakened  heart,  and  were  connected 
with  engorgement  of  the  other  viscera  under  a  similar  dependence.  This 
was  eminently  true  of  the  lungs  and  liver.  No  doubt  it  was  the  giving 
way,  functionally,  of  several  important  organs  that  was  the  cause 
of  death.  Whilst  this  is  true,  it  is  also  highly  probable  that  the  con- 
dition of  the  kidneys,  which  had  become  more  and  more  insufficient,  gave 
the  terminal  features  of  the  combined  conditions,  to  a  greater  degree 
than  any  other  of  the  organs  involved. 

Case  IV. — A  broker;  bachelor;  thirty  years  old;  of  a  nervous, 
excitable  temperament ;  suffers  somewhat  from  symptoms  of  flatulent 
dyspepsia  and  irritable  heart.  His  bowels  are  frequently  torpid ;  his 
urine  habitually  slightly  high-colored.  Habits  are  temperate — drinks 
little;  does  not  smoke.  No  gout  or  rheumatism.  After  an  elaborate 
dinner  at  which  he  drank  different  wines — but  not  to  the  point  of  in- 
ebriety— he  went  home  and  slept.  In  the  early  morning  he  had  repeated 
attacks  of  vomiting  and  diarrhoea.  Accompanying  these  symptoms 
there  was  moderate  headache  and  annoying  palpitations.  His  pulse 
was  rapid,  weak,  depressible,  and  irregular.  His  heart  action  was  also 
much  disturbed;  it  was  rapid,  irregular,  and  the  pulse  weakened. 
There  was  a  soft  systolic  bruit  accompanying  the  second  sound  over  the 
pulmonary  area.  Apparently  the  cardiac  cavities  were  somewhat  dilated. 
The  tongue  was  clean,  and  yet  nausea  was  distressing.  No  tenderness 
over  the  epigastrium  or  anywhere  in  the  abdominal  cavity.  The  urine 
had  been  smaller  in  quantity  since  the  night  previous,  and  instead  of 
being  dark  in  color,  was  very  light.     Under  the  use,  first,  of  ammonia 


TREATMENT    OF     UREMIC    SYMPTOMS.  21 

and  bismuth,  with  broths,  milk,  Vichy,  and  rest  in  bed,  he  improved 
rapidly.  Plis  heart  grew  stronger  ;  his  urine  became  more  concentrated 
and  larger  in  quantity. 

When  the  first  symptoms  disappeared,  strophanthus  and  nux  vomica 
were  added  to  the  previous  treatment. 

Such  cases  as  the  foregoing  may  be  differently  designated,  I  am  quite 
aware,  and  at  times  are  considered  of  little  moment  and  scarcely  worthy 
of  very  careful  consideration.  I  have  known  many  such  attacks  re- 
garded as  the  usual  outcome  of  excesses  of  the  table,  and  put  down  in 
doubt,  if  we  mean  by  that  to  express  the  idea  that  the  liver  is  incident- 
ally interfered  with  as  to  its  physiological  function  ;  but  while  this  may 
be  true,  I  claim  now  that  such  cases  are  correctly  interrupted  in  recog- 
nizing that  the  kidneys,  by  their  temporary  insufficiency,  occasion  most 
of  the  symptoms  reported,  in  a  very  direct  manner.  It  is  also  evident 
that  strengthening  the  cardiac  contractions  and  giving  more  vascular 
tone  to  the  general  circulation  will  be  found  useful.  These  indications 
may  indeed  be  urgent.  Is  it  not  obvious,  however,  that  it  is  the  reten- 
tion in  the  economy  of  the  waste  substances,  made  suddenly  enormous 
by  reason  of  dietary  indiscretion,  which  brings  on  the  threatening  symp- 
toms which  require  relief  by  all  rational  methods  ?  Nature  makes  every 
effort  in  these  cases,  by  frequently  repeated  vomiting  and  purging,  to 
clear  the  body,  through  these  natural  emunctories,  of  the  poisonous  fer- 
menting ingesta  which  enter  so  largely  as  a  factor  in  the  direct  causation 
of  such  explosions.  The  rest  in  bed ;  the  gentle  and  continuous  warmth 
to  the  surface ;  the  liquid  diet,  which  is  the  most  rational  diuretic  as 
well  as  food,  the  quieting  effect  of  the  ammonia  and  bismuth  on  the 
irritated  stomachal  mucous  membrane,  and  the  stimulating  influence  of 
the  former  in  relieving  general  depression,  were  rapidly  followed  by 
beneficial  effects.  As  soon  as  practicable  the  heart  was  strengthened 
and  regulated  to  overcome  the  effects  of  diminished  arterial  tension 
throughout  the  body,  but  particularly  in  the  kidneys,  whose  functions 
should  be  re-established  in  order  to  restore  equilibrium  to  the  economy. 

Case  V. — A  maiden  lady,  forty-five  years  old,  thin  and  spare  of  body, 
passed  her  menopause  without  functional  disturbances ;  she  has  always 
been  healthy  and  vigorous ;  has  a  good  appetite  and  digestion  ;  bowels 
regular ;  heart  action  normal ;  no  malaria,  rheumatism,  or  gout. 
Patient  suffers  from  obstinate,  recurrent  headaches  every  morning. 
After  she  awakens,  gets  her  coffee  and  a  light  breakfast,  they  frequently 
disappear,  or  become  less  intense.  At  times  they  continue  during  many 
hours  of  the  day,  and  only  disappear,  completely,  without  apparent 
cause,  to  return  again  the  following  morning.  The  urine  is  normal  in 
quantity,  rather  light  in  color,  containing  no  abnormal  substances.  In 
this  case  there  was  no  cardiac  hypertrophy  and  no  increased  vascular 
tension — at  least,  neither  one  nor  the  other  could  be  affirmed  after 
careful  examination.  Almost  every  rational  explanation  of  the  head- 
aches was  attempted,  and  on  each  occasion   followed  up  by  appropriate 


28  TREATMENT    OF    UREMIC    SYMPTOMS. 

treatment  of  the  supposed  cause,  without  beneficial  effect.  Finally,  I 
thought  that  imperfect  elimination  of  the  products  of  mal-assimilation 
through  kidneys  functionally  insufficient,  and  which  possibly  were 
affected  with  the  precursory  stage  of  interstitial  nephritis,  might  account 
for  the  headaches.  Thereupon  I  prescribed  nitroglycerin  in  the  ordi- 
nary dose  of  one  minim  of  a  one  per  cent,  solution  every  four  hours, 
and  very  soon  the  headaches  were  relieved,  if  not  cured.  I  now  felt 
tolerably  sure  that  my  interpretation  of  the  case  was  correct. 

I  might  multiply  examples  of  different  kinds  pointing  to  what  I 
would  call  insufficiency  of  renal  excretion,  with  many  minute  details, 
but  this  narrative  would  merely  prove  wearisome. 

In  many  instances  of  obstinate  nasal,  naso-pharyngeal,  laryngeal,  and 
tracheal  inflammation,  chronic  in  type,  I  am  now  firmly  convinced  that 
the  inactive  functional  condition  of  the  kidneys  is  the  primary  cause  of 
these  inflammations.  An  imperfect  blood -supply,  containing  in  it  many 
elements  which  should  be  eliminated  through  the  kidneys,  is  rendered  a 
source  of  morbid  manifestations  in  the  whole  mucous  tract — sometimes 
of  the  respiratory  organs,  sometimes  of  the  organs  of  digestion  and 
assimilation.  Doubtless,  also,  the  renal  congestion  which  originates,  as 
it  were,  this  vicious  circle  is  heightened  and  made  more  intense  by  the 
blood  loaded  with  excrementitious  substances,  which  come  to  the  kid- 
neys continuously,  and  which,  provisionally,  they  are  unable  to  get  rid 
of.  In  such  cases  I  have  often  found,  after  the  bowels  had  been  freely 
moved,  and  the  mucous  linings  capable  of  being  reached  with  suitable 
topical  applications  had  been  treated,  that  a  diuretic  solution,  such  as 
the  liquor  amraonii  acetatis,  frequently  given,  produced  the  happiest 
results  after  it  had  been  taken  during  several  days  in  a  regular  manner. 

I  have  noticed  the  preceding  conditions  on  several  occasions  follow 
bad  colds,  of  the  nature  of  grippe,  or  attack  of  influenza,  and  in  these 
instances  have  assumed  that  the  specific  nature  of  the  disorder  of  the 
respiratory  tract  and  general  system  had  much  to  do  with  the  evidences 
later  on  of  renal  insufficiency.  In  other  cases,  in  which  there  could  be 
no  doubt,  to  my  mind,  that  there  were  organic  changes  in  the  kid- 
neys of  the  nature  of  chronic  parenchymatous  or  interstitial  nephritis, 
by  reason  of  the  specific  gravity  of  the  urine,  the  deposit  of  albumin 
frequently  contained  in  it,  and  the  frequency  with  which  different  kinds 
of  tube-casts  were  found  on  microscopical  examination,  I  have  found 
the  symptoms  referred  to  in  the  cases  reported,  but  seemingly  of  graver 
significance,  because  they  were  united  with  manifest  organic  renal 
changes.  Almost  invariably,  as  we  know,  all  undue  fatigue,  intense 
emotional  excitement,  errors  of  diet  or  drink,  cold  and  exposure,  will 
aggravate  renal  disease  and  bring  on,  rapidly  or  slowly,  disquieting 
symptoms.  Knowing  the  previous  condition  of  the  kidneys,  we  can 
never  prudently  ignore  this  knowledge  when  we  care  for  such   patients. 


TREATMENT    OF    UREMIC    SYMPTOMS.  29 

Cask  VI. — A  distinguished  architect  Of  New  York  has  been  one  of 
my  patients,  off  and  on,  for  at  least  eighteen  years — indeed,  during 
nearly  all  my  professional  life.  This  gentleman,  now  over  sixty  years 
of  age,  is  a  man  of  great  industry,  great  talents,  and  remarkable  pro- 
fessional success.  Once  or  twice  in  the  course  of  every  year  he  has  an 
acute  gouty  attack  affecting  the  metatarso-phalangeal  joint  of  the  big 
toe  of  one  or  the  other  foot.  Sometimes  these  gouty  attacks  in  the  small 
joints  of  the  feet  come  on  without  premonition  ;  sometimes  a  bronchial 
or  slightly  asthmatic  attack  precedes  them.  During  the  whole  period  I 
have  taken  care  of  this  patient  he  has  had  urine  light  in  color,  of  low 
specific  gravity,  containing  a  variable  quantity  of  albumin  and  some 
granular  and  hyaline  casts.  Whenever  these  bronchial,  or,  frankly 
speaking,  gouty  attacks  are  upon  him,  and  in  view  of  my  knowledge  of 
the  condition  of  his  kidneys,  I  am  always  very  solicitous  in  regard  to 
their  outcome.  I  have  seen  him  when  the  thoracic  oppression  was  very 
intense,  the  heart  beating  irregularly,  rapidly,  and  feebly,  and  the  pallor 
and  pinched  expression  of  the  face  were  striking  and  alarming.  Ac- 
companying this  condition  there  were  disseminated  moist  and  sonorous 
rales  in  the  chest,  and  the  urine  looked  almost  watery,  and  was  dimin- 
ished notably  in  quantity.  Under  these  circumstances  I  have  found 
that  repeated  doses  of  colchicine  and  the  free  use  of  Fried richshall 
water  were  the  most  useful  medicinal  remedies  to  employ.  Rest  in  bed 
and  fluid  diet  were  insisted  upon,  and  in  some  instances  counter-irrita- 
tion or  revulsion  to  the  back  was  deemed  advisable.  Subsequent  to 
such  attacks,  giving  up  business  affairs  and  travel  were  strongly 
favored,  and  when  indulged  in,  rapidly  brought  about  a  state  of  well- 
being  and  the  return  to  usual  conditions. 

In  the  evident  gouty  cases,  and  particularly  in  those  where  the  heart- 
action  is  good  and  the  tension  in  the  arteries  not  excessive,  colchicine  is 
a  more  valuable  remedy  than  nitroglycerin.  In  instances,  on  the  con 
trary,  in  which  the  arterial  tension  is  well  marked  or  excessive  and  the 
heart  laboring,  whilst  the  quantity  of  urine  is  small  and  low  in  specific 
gravity,  I  believe  it  is  wise  to  begin  treatment  with  nitroglycerin  or  the 
nitrites.  In  any  very  alarming  expression  of  this  condition,  inhalations 
of  nitrite  of  amyl  should  first  be  employed.  We  shall  sometimes  be 
disappointed  in  the  efficacy  of  these  agents,  and  it  is,  I  believe,  when- 
ever we  have  been  committed  to  the  error  of  believing  that  there  is 
hypertension  in  the  peripheral  arterial  system,  connected  or  not  with 
spasm  in  the  vessels  of  the  kidneys,  or  some  other  important  viscus. 
Frequently,  the  so-called  increased  arterial  tension  is  merely  the  conse- 
quence of  atheromatous  thickening  of  vascular  walls,  and  the  blood, 
instead  of  being  under  too  great  pressure,  requires  increase  of  the  vis  a 
tergo  to  make  it  circulate  more  freely  and  with  greater  energy.  This 
may  often  be  attained  by  the  use  of  caffein  or  digitalis,  and  as  a  result 
of  the  effective  use  of  one  or  both  of  these  remedies,  we  are  forced  to 
conclude  that  the  renal  phenomena  proceed  directly  from  an  enfeebled 
heart,  and  the  true  way  of  managing  such  cases  is  really  not  to   make 


30  TREATMENT    OF    UKJEMIC    SYMPTOMS. 

so  direct  an  appeal  to  the  kidneys,  in  the  first  place,  but  rather  to  the 
muscular  heart-structure.  In  strengthening  the  latter  we  help  the 
former  in  a  much  more  obvious  and  important  manner.  When,  how- 
ever, we  are  not  quite  sure  to  what  extent  the  kidneys  originate  the 
series  of  pathological  events  and  also  tend  to  keep  them  up,  it  is  judi- 
cious to  watch  very  carefully  the  administration  of  digitalis.  I  am  con- 
vinced that  whenever  the  renal  function  is  remarkably  insufficient  and 
the  urine  is  greatly  diminished,  or  perhaps  wholly  suppressed,  we  are 
liable  to  have  those  curious  phenomena  in  the  heart- beats  and  in  the 
pulse,  not  to  speak  of  nausea  and  vomiting,  which  show  accumulation 
of  this  drug  and  its  poisonous  effects  upon  the  economy.  In  many 
instances  it  is  relatively  simple  to  distinguish,  in  a  differential  way,  the 
part  played  by  the  two  conditions  relative  to  cause  and  effect.  In 
others,  we  are  left  in  great  and  reasonable  doubt,  and  our  judgment 
in  the  matter  remains  most  uncertain. 

In  regard  to  the  simple  question  of  the  amount  of  arterial  tension  in 
the  radial  arteries,  I  know  of  nothing  more  difficult  at  times  than  to 
accurately  estimate  it — one  reason  being,  besides  the  one  already  given, 
the  amount  of  soft  tissues  about  the  artery  at  the  wrist.  Even  with  the 
use  of  the  sphygmograph  we  may  be  unable  to  decide  the  matter,  for 
the  simple  reason  that  tracings  with  this  instrument  are  only  valuable 
when  made  by  an  expert.  Otherwise,  we  are  liable  to  run  into  very 
great  errors  of  interpretation.  This  is  mainly  due  to  the  fact  that  it  is 
very  difficult  to  fit  the  instrument  on  any  wrist  so  that  we  can  form  a 
perfect  estimate  of  the  directness  and  accuracy  of  its  pressure  over  the 
artery. 

Case  VII. — A  widow,  of  large,  bulky  frame,  about  sixty  years  of  age  ; 
takes  very  little  exercise,  but  drives  a  great  deal  and  lives  most  of  the 
time  in  the  open  air,  in  summer  at  Newport,  in  winter  at  Cannes. 
She  is  careful  with  her  diet,  as  a  rule,  but  commits  occasional  impru- 
dences in  eating  rich  or  sweet  food  ;  almost  invariably  she  pays  the 
penalty  of  these  errors  by  nausea,  stomachal  distress,  pallor,  and  a  sub- 
icteric  hue  of  the  skin.  The  pulse  becomes  weak,  rapid,  and  depressi- 
ble,  the  heart  action  fluttering  and  feeble ;  sometimes  the  bowels  are 
torpid  ;  sometimes  there  is  and  has  been  more  or  less  diarrhoea,  amount- 
ing to  several  loose  movements  in  the  twenty-four  hours.  I  have  known 
the  attacks  once  or  twice  to  be  of  a  different  kind ;  instead  of  the  pre- 
vious symptoms,  the  head  ached  intensely ;  there  was  torpor  and  somno- 
lence ;  the  speech  was  thick,  the  ideas  came  sluggishly  ;  the  face  was 
somewhat  drawn  down  on  one  side ;  the  pupils  were  contracted,  and  there 
was  more  or  less  nervous  irritability,  as  shown  by  slight  fibrillary  muscular 
twitchings.  Seven  or  eight  years  ago,  at  the  period  of  these  latter 
symptoms,  the  urine  was  ordinarily  of  low  specific  gravity,  moderate  or 
abundant  in  amount,  and  containing  a  small  quantity  of  albumin  and 
granular  casts.  Although  the  patient  had  been  told  that  her  condition  was 
gouty,  and  this  was  true  in  a  certain  sense,  yet  she  had  never  had  either 
a  frankly  determined  attack  of  gout  or  rheumatism.  Compound  cathar- 


TREATMENT    OF    UREMIC    SYMPTOMS.  31 

tic  pills,  strophanthus,  digitalis,  and  nitroglycerin  have  all  been  useful 
at  times,  and  singular  to  say,  the  use  of  Warburg's  extract  has  some- 
times enabled  me  to  be  of  the  most  manifest  benefit,  when  the  other 
agents  completely  failed.  I  suspected,  therefore,  very  strongly,  a  malarial 
element,  without,  however,  being  able  confidently  to  affirm  it.  Some- 
times I  have  thought  it  possible  that  Warburg's  extract  was  useful 
simply  as  an  hepatic  stimulant,  and  thus  helped  notably  to  relieve 
evident  ursernic  phenomena.  Whenever  I  had  gotten  rid  of  the  threat- 
ening phenomena  in  this  case  for  a  time,  I  insisted  upon  a  milk  diet, 
koumyss,  matzoon,  milk  and  Vichy,  etc.;  massage  daily,  or  every  other 
day  ;  oxygen  inhalations  and  repeated  doses  of  digitalis  in  tablet  triturate 
form.  Every  winter  and  spring,  for  several  years,  I  have  sent  her  to  the 
south  of  France,  and  thus  far  she  has  held  her  own,  and,  indeed,  I 
should  say,  to-day  she  is  in  better  physical  condition  than  she  was 
several  years  ago. 

In  the  preceding  case  and  the  one  narrated  before  it  I  have  more 
than  once  seen  what  I  believed  to  be  evident  and  pernicious  effects 
resulting  from  the  use  of  even  small  doses  of  opium  or  morphine  in 
some  form — given  by  the  mouth,  for  I  have  never  had  occasion  to  resort 
to  the  use  of  morphine  hypodermatically  in  either  of  the  preceding  cases. 
One  of  the  interesting  features  in  my  last  case  is  this  :  During  the  past 
two  years  the  character  of  the  urine  has  changed  in  a  remarkable 
manner  ;  as  a  rule,  this  is  no  longer  light-colored,  of  low  specific  gravity, 
containing  albumin  and  granular  casts;  on  the  contrary,  it  is  of  a  fairly 
deep  color,  does  not  generally  contain  any  albumin,  and  on  several 
occasions  has  shown  no  casts  when  examined  very  carefully  and  by 
expert  microscopists.  What  is  my  conclusion  ?  Have  I  cured  a  case  of 
interstitial  nephritis  or  not  ?  I  will  not  pretend  to  solve  this  difficult 
question.  I  would  simply  report  a  very  interesting  clinical  fact  in  my 
own  private  experience,  of  which  there  may  be  many  in  that  of  my 
listeners,  so  far  as  I  know. 

I  now  wish  to  speak  of  the  use  of  opiates,  and  more  particularly  of 
morphine  in  these  latter  cases,  whenever  respiratory  or  other  symptoms, 
such  as  obstinate  or  distressing  insomnia,  seem  to  require  their  employ- 
ment. Personally,  I  am  and  always  have  been  much  opposed  to  the  use 
of  opiates,  and  especially  of  morphine  hypodermatically,  whenever  used  in 
cases  of  chronic  Bright's  disease,  except  in  very  minute  doses.  I  believe 
I  have  seen  it  do  harm  so  often  in  locking  up  the  secretions,  when  just 
the  contrary  was  imperatively  required — in  bringing  out  further  symp- 
toms of  uraemia,  acute  or  chronic — that  it  appears  to  me  reasonable  to 
abstain  from  this  medication  as  long  as  possible.  If  its  use  is  forced 
upon  me  by  symptoms  that  I  have  vainly  endeavored  to  relieve  by  other 
drugs  which  are  more  innocent  in  their  effects,  I  always  make  use  of  it 
with  great  care  and  watchfulness. 

There  are  times,  however,  when  I  do  not  feel  in  this  way,  and  where 
ursernic  symptoms  are  unquestionably  manifest.     In  general  terms,  these 


32  TREATMENT    OF    UREMIC    SYMPTOMS. 

are  the  cases  in  which  the  heart  is  the  weak  organ  primarily,  and  in  which 
the  kidneys  will  be  greatly  helped  by  .cardiac  stimulation  of  an  active 
kind.  Of  the  numerous  drugs  which  strengthen,  quiet,  and  regulate  a 
weakened,  dilated  heart,  none  at  times  is  comparable  to  the  hypodermatic 
use  of  morphine  in  small  or  moderate  doses.  Therefore,  when  this  condition 
is  obviously  the  cause  of  the  distressiug  or  threatening  symptoms,  I  am 
not  unwilling  to  recur  to  its  use.  If  blood  pressure  is  low,  as  shown  by 
slight,  imperfect  arterial  tension  in  the  radials,  and  if  the  pupils  are 
normal  or  somewhat  dilated,  with  the  previous  condition  also  clearly 
denned,  I  am  not  averse  to  morphine  medication  in  the  manner  I  have 
mentioned.  Unquestionably,  when  thus  employed,  I  have  had  no  good 
reason  myself  to  regret  making  use  of  it.  When,  however,  with  the 
weak,  irregular,  or  failing  heart,  are  also  present  the  pulse  of  lowered 
tension  and  the  contracted  pupil,  then  I  would  cry  halt  !  because  I 
believe  these  conditions  often  mean  poisoning  from  retention  in  the 
system  of  excrementitious  substances  of  different  sorts  and  more  or  less 
poisonous,  which  may  rapidly  overwhelm  the  economy  in  their  disas- 
trous effects  unless  the  clear  indications  of  treatment  are  distinctly  made 
out  and  followed  by  the  practitioner.  Again,  in  cases  where  we  are  in 
great  and  legitimate  doubt — as  we  frequently  are — despite  our  most 
careful  scrutiny  of  a  given  case,  as  to  which  organ,  the  heart  or  the 
kidneys,  most  evidently  needs  immediate  help — in  these  cases  I  advise 
against  morphine  hypodermatically  as  long  as  possible,  on  account  of  the 
possible  immediate  and  great  harm  which  may  follow  its  use. 

Alongside  of  these  cases,  and  as  a  further  development  of  similar 
underlying  conditions,  is  what  we  often  see,  i.  e.,  ursemic  convulsions 
actually  take  place.  The  quite  general  teaching  of  more  than  twenty 
years  in  New  York  City,  owing  perhaps  more  to  Prof.  Loomis's  influence 
as  a  very  prominent  clinician  than  to  anyone  else,  has  been  to  the  effect 
that  morphine  hypodermatically  in  large  and  repeated  doses  in  acute 
uraemia  has  done  what  no  other  drug  with  which  we  are  familiar  will  do 
It  will  bring  the  convulsive  seizure  to  a  rapid  termination ;  it  will  at 
times  prevent  the  recurrence  of  it  ;  it  will  break  up  arterial  spasm,  it 
will  thus  lessen  arterial  pressure ;  it  will  promote  diaphoresis ;  it  will 
greatly  increase  the  bulk  of  the  urine  when  this  secretion  is  diminished 
or  almost  suppressed ;  it  will  bring  back  to  life  when  hope  seems  almost 
lost. 

In  view  of  the  facts  so  graphically  and  forcibly  brought  to  our  atten- 
tion by  Dr.  Loomis — narrated  with  all  the  clearness,  talent,  and  ability 
which  characterize  his  work — we  should  be  loath  to  throw  aside  the 
instruction  offered  by  the  close  study  of  his  cases.  Inasmuch,  how- 
ever, as  I  have  seen,  I  believe,  disastrous  results  follow  this  kind  of  inter- 
ference; and  when  these  results  could  not,  in  my  judgment,  be  properly 
explained  by  the  natural  development  of  the  renal  disease,  it  is  only 


TREATMENT    OF    UREMIC    SYMPTOMS.  33 

right  that  I  should  endeavor  to  seek  for  the  cause  of  this  discrepancy. 
I  have  allowed  my  reasons  to  be  seen  in  part  in  my  foregoing  remarks, 
and  I  would  further  add  that  whenever  the  convulsive  seizure  of  acute 
uraemia  is  evidently  directly  occasioned  by  a  spasmodic  condition  of  the 
vessels  of  the  kidneys,  and  this  spasm  is  more  or  less  general  in  the 
bloodvessels  of  the  body,  including  in  many  cases  the  cerebral  mass  and 
the  medulla  oblongata,  I  have  little  doubt  that  the  remedial  effects  of 
morphine  injections,  in  tiding  over  a  most  critical  period  of  disease,  are 
very  remarkable.  But  let  us  bear  in  mind,  as  the  perusal  of  Loomis's 
cases  and  numerous  others  will  distinctly  show,  that  the  convulsive  seiz- 
ures were  accompanied  with  dilated  pupils  and  a  more  or  less  disturbed, 
perhaps  weak,  heart  action.  Moreover,  in  the  coma  which  habitually 
follows  just  such  attacks,  after  the  use  of  morphine,  or  sometimes, 
indeed,  without  its  use,  the  pupil  may  become  of  pin-hol*  size,  or  very 
much  contracted  ;  the  heart  maybe  laboring  just  as  much,  or  even  more, 
and  the  kidneys  may  not  secrete  an  increased  quantity  of  urine.  I 
regard  such  cases  as  being  among  those  in  which  the  system  is  even  more 
overwhelmed  with  the  so-called  ursemic  poison  than  the  previous  ones, 
and  to  which  I  would  fain  direct  closest  attention. 

In  this  translation  of  the  immediate  or  prolonged  effects  of  renal  in- 
sufficiency, of  systemic  poisoning  thus  occasioned,  whether  occurring  in 
Bright's  disease  or  in  mere  functional  disorder,  we  must  look  to  several 
concealed  factors  involved  in  the  clinical  estimate  which  we  should 
make.  In  one  aspect,  the  kidney  is  nothing  more  than  an  ordinary 
filter ;  in  another,  it  is  an  elective  filter,  depending,  no  doubt,  for  this 
power  in  part  upon  the  precise  anatomical  and  pathological  conditions 
affecting  it ;  depending  also  upon  dynamic  or  vital  forces,  in  regard  to 
which  we  are  almost  in  the  dark  even  at  the  present  day.  Suffice  it  to 
add,  however,  that  strictly  scientific  investigations,  more  particularly  of 
Feltz  and  Ritter  and  of  Bouchard,  have  shown  how  various  are  the 
poisonous  ingredients  of  the  urine,  and  how  it  is  that  at  different  times 
the  kidneys  will  allow  some  of  these  poisons  to  pass  through  them,  and 
again  will  not.  Besides,  the  effects  of  the  retained  poisons  are  very 
different  according  to  their  nature — some  doubtless  accounting  more 
than  others  for  the  pupillary  and  nervous  symptoms ;  some  producing 
excitement,  others  depression,  lowered  temperature,  somnolence,  and 
torpor. 

These  different  poisons  may  also  be  eliminated  from  the  economy  even 
at  short  invervals  in  unequal  amounts,  and,  of  course,  different  morbid 
effects  are  thus  produced,  or  similar  effects  in  the  unequal  degree,  in  view 
of  the  combined  nature  or  quantity  of  the  retentions  in  the  economy. 

We  should  also  be  now  convinced  of  another  fact,  and  it  is  that 
neither  the  condition  of  the  kidneys  nor  the  heart,  as  shown  by  patho- 
logical researches,  will  prove  satisfactorily,  in  many  instances,  the  cause 


34         TREATMENT  OF  UREMIC  SYMPTOMS. 

of  the  ursemic  symptoms  or  seizures.  We  are,  therefore,  forcibly  com- 
pelled to  look  for  the  source  or  primary  cause  of  the  symptoms  elsewhere, 
and  it  is  often  in  the  digestive  tract  that  we  shall  most  certainly  find 
them.  The  control  of  the  quality  and  quantity  of  the  ingesta ;  the 
proper  and  prolonged  neutralization  of  poisons  continuously  produced 
in  this  system,  will  thus  become  a  means  of  prophylaxis  against  ursemic 
developments  of  milder  or  greater  intensity,  which  will  be  found  second 
to  none.  So  soon  as  the  most  urgent  symptoms  of  acute  uraemia  are 
neutralized  or  antagonized,  judicious  antisepsis  of  the  digestive  tract  is 
a  treatment  which  has  the  greatest  value.  Among  drugs  useful  in 
carrying  out  this  remedial  indication,  I  would  speak  favorably,  from 
repeated  experience,  of  salicylate  of  bismuth  and  beta-naphthol. 

In  conclusion,  I  would  add  that  I  am  convinced  in  very  many  such 
case3,  especially  among  the  residents  of  our  cities,  in  the  winter  time, 
oxygen  gas  by  inhalation  several  times  daily,  plays  a  very  important 
remedial  role.  Banishment  to  a  warm,  equable  climate  for  the  cold  or 
variable  months  of  the  year  is,  of  course,  generally  speaking,  a  far  better 
substitute  than  artificial  inhalations  of  oxygen  ;  but  this  plan,  I  regret 
to  say,  is  often  wholly  impracticable. 


A  CONTRIBUTION  TO  THE  TREATMENT  OF  ORGANIC 
DISEASE  OF  THE  HEART. 


Onk  always  writes  about  a  subject  which  has  been  considered 
frequently  with  some  hesitancy.  No  doubt  this  depends  upon  several 
facts  :  First,  we  feel  we  have  nothing,  it  may  be,  very  new  to  add  to  our 
common  stock  of  knowledge  ;  or,  we  are  persuaded  that  no  matter  how 
carefully  we  may  study  and  observe  what  we  see  daily,  similar  work  has 
been  done  by  men  of  acute  mind  and  long  training  in  our  profession, 
and  that  they  have  left  very  little  to  be  said  by  those  who  come  later  in 
the  day.  Moreover,  we  know  that  the  work  we  are  familiar  with  is  often 
of  the  best  kind,  and  we  are  careful  lest  our  little  offering  be  regarded  as 
insignificant  in  character  and  in  bearing.  Still,  it  is  given  to  every 
earnest  worker  to  note  things  which  have  some  new  aspects,  and  which 
may  be  estimated  in  an  individual  manner,  which  is  at  times  both  inter- 
esting and  instructive  to  his  readers. 

One  of  the  facts  which  is  most  prominent  in  my  estimate  of  organic 
affections  of  the  heart  is  that  which  shows  the  little  need,  at  times,  of 
treating  heart  disease  merely  because  a  murmur  is  present.  How  often 
does  this  exist  without  symptoms  !  How  frequently  an  accidental  exam- 
ination reveals  it !  Why,  then,  treat  it?  We  must,  first  of  all,  consider 
the  patient.  If  accompanying  the  murmur  there  be  rational  symptoms 
of  cardiac  incompetency,  such  as  pain,  dyspnoea,  palpitations,  and  if  to 
these  be  added  hypertrophy  or  dilatation,  there  can  be  no  question  that 
properly  instituted  medication  may  be  of  great  service  and  relieve  all 
distress  for  a  while.  In  administering  drugs  we  must  recognize,  however, 
that  we  give  them  for  the  purpose  of  relieving  symptoms  or  diminishing 
the  complicating  conditions,  not  to  cure  chronic  valvular  disease ;  once 
the  latter  is  well  established  it  is  there  to  remain,  and  our  effort  should 
be  not  to  cure,  but  to  prevent  it  from  becoming  really  injurious  by 
reason  of  its  possible  effects. 

Perfect  compensation  in  chronic  disease  is  what  we  wish,  and  seek  to 
attain  when  it  is  broken.     When  it  is  present  no  treatment  is  required. 

One  great  cause,  as  we  know,  of  most  valvular  affections  is  rheu- 
matism. Sometimes,  with  all  the  care  we  can  exercise  in  the  manage- 
ment of  this  affection,  cardiac  disease  will  accompany  its  acute  course, 
or  follow  sooner  or  later  as  a  lamentable  sequela.  And  yet  it  frequently 
seems  to  us,  if  the  disease  were  managed  with  more  care  and  intelligence, 


36  ORGANIC     DISEASE     OF    THE    HEART. 

as  though  there  might  be  fewer  instances  of  heart  disease.  Different 
treatments  of  acute  rheumatism  have  been  thought  to  lessen  the  liability 
to  intercurrent  or  later  cardiac  complications.  My  own  tendency  has 
always  been  to  give  an  alkaline  treatment,  sometimes  by  means  of 
bicarbonate  of  soda  and  Rochelle  salts  in  moderate,  frequently-repeated 
doses,  sometimes  with  acetate  of  potash  and  chloride  of  ammonium. 
Either  of  these  combinations  appears  to  me  preferable  to  the  use  of  the 
salicylates  in  neutralizing  the  bad  effects  of  acute  rheumatism.  I  have 
occasionally  been  of  the  opinion  that  the  duration  of  the  disease  in  its 
acute  form  was  thus  lessened.  I  am  confident  that  the  pain  of  the 
disease  is  frequently  diminished  in  a  marked  degree.  In  a  few  cases, 
where  the  temperature  is  high,  the  pulse  bounding,  I  have  used  additions 
of  small  doses  of  aconite  to  the  second  mixture  for  a  few  days,  with 
apparently  very  good  effects.  Of  course  it  is  important  each  day  during 
the  active  stage  of  the  disease  to  watch  closely  the  condition  of  the  heart ; 
sometimes  endocarditis  will  betray  itself  easily  by  a  marked  increase  of 
local  pain,  dyspnoea,  fever,  general  prostration.  Not  seldom  it  is  only 
by  the  closest  attention  that  we  can  discover  the  beginning  of  the  valvular 
inflammation.  It  is  very  important,  however,  to  recognize  it  when  it  is 
present,  for  by  its  careful  management  at  the  period  of  its  inception,  we 
can  ward  off  the  chronic  and  incurable  consequences  which  may  follow 
under  other  circumstances. 

Rest  in  bed  in  acute  endocarditis  is  all-important,  so  as  to  reduce  as 
far  as  possible  cardiac  activity.  And  not  only  is  this  confinement  to  bed 
essential  during  the  febrile  acute  stage  of  endocarditis,  but  it  should  be 
kept  up  for  many  days  after  this  is  over  and  when  the  rheumatic  pains 
are  no  longer  very  pronounced.  Even  after  the  patient  sits  up,  par- 
ticular attention  should  be  paid  him,  and  so  soon  as  he  shows  signs  of 
fatigue  he  must  immediately  return  to  bed. 

Nothing  gives  cardiac  dilatation  more  readily  than  too  great  strain  or 
fatigue  after  acute  disease,  especially  when  the  type  of  it  is  at  all  severe 
or  it  has  lasted  any  length  of  time.  In  this  respect,  however,  individuals 
differ  greatly,  and  what  in  one.  case  would  seem  even  beneficial  to  the 
patient,  and  allows  his  cure  to  go  speedily  onward,  in  another  will  appear 
to  retard  convalescence  evidently,  and  instead  of  being  of  service  is,  on 
the  contrary,  a  positive  injury.  The  ability  to  discriminate  between  the 
different  powers  of  resistance  of  various  individuals,  in  other  words,  to 
lay  down  an  exact  measure  of  their  vital  force,  is  one  of  the  difficult  and 
arduous  problems  of  medicine.  We  can  never  precisely  gauge  it  in  any 
two  cases,  no  matter  how  much  alike  they  seem  to  be,  and  the  result  is 
that  we  frequently  deceive  ourselves  and  are  led  into  woful  error,  even 
when  we  wish  most  to  avoid  it. 

No  doubt  hereditary  tendency  shows  itself  in  some  of  these  examples 
of  cardiac  weakness  following  acute  disease,  and  if  we  go  into  family 


ORGANIC    DISEASE    OF    THE    HEART.  37 

history  closely  we  may  obtain  facts  which  will  be  of  real  service,  by 
enabling  us  to  forewarn  our  patients,  and  thus  ward  off  from  them  the 
results  of  real  imprudence  and  consequent  heart-strain.  Later  on,  after 
a  patient  has  left  his  bed,  strict  rules  for  the  government  of  habits  and 
dietary  are  valuable,  and  when  strictly  followed  are  productive  of  good 
results. 

The  occupation  is  one  of  the  subjects  to  which  close  attention  should 
be  given.  If  it  be  very  laborious  physically  or  mentally,  heart  dilata- 
tion may  readily  occur,  and  ere  long  the  patient  will  give  many  signs  of 
lowered  vitality  and  cardiac  weakness.  Thus  it  becomes  a  duty  on  the 
part  of  the  professional  adviser,  especially  when  the  patient  is  youthful, 
to  inquire  into  what  is  to  be  his  future  line  of  work,  and  if  it  be  dis- 
covered to  be  injurious,  to  strike  a  warning  note,  which,  though  un- 
heeded at  the  time,  will,  nevertheless,  be  thoughtfully  regarded  when 
the  patient  shows  signs  of  waning  strength  or  lack  of  recuperative 
power.  Unfortunately,  there  are  many  people  who  only  listen  to  the 
physician  when  actual  physical  trouble  is  upon  them,  and  then  it  is  often 
too  late  wholly  to  remedy  all  the  disastrous  consequences  brought  on  by 
inattention,  folly,  or  ignorance.  Even  when  the  valvular  disease  is 
clearly  present,  it  is  harmful  to  treat  it  unless  cardiac  compensation  be 
broken. 

The  regular  routine  of  one's  daily  life  alone  should  be  carefully 
watched  and  attended  to  in  accord  with  the  rules  of  a  proper  hygiene  for 
obtaining  the  best  heart-power  for  the  individual.  These  rules  pertain 
to  the  regulation  of  diet,  exercise,  clothing,  mental  occupation,  bathing, 
and  the  use  of  stimulants. 

In  order  to  carry  out  our  wishes  in  regard  to  all  these  matters — as  it 
is  not  something  that  can  be  taken  up  for  a  while  and  then  abandoned — 
it  is  often  wise  to  inform  our  patient  as  to  the  precise  nature  of  his 
trouble,  so  as  to  make  him  readier  to  follow  exactly  the  regimen  that  we 
shall  mark  out  for  him,  and  thus  attain  the  nearest  approach  to  a  con- 
dition of  continuous  cardiac  compensation.  It  is,  however,  often 
hazardous  to  tell  a  patient  that  he  has  heart  disease.  If  he  is  very  im- 
pressionable he  becomes  thoughtful  about  himself,  nervous,  excitable, 
and  highly  apprehensive.  Once  such  patients  have  acquired  the  idea 
they  have  heart  disease  they  continue  to  be  unhappy  and  melancholic 
despite  our  best  efforts  to  relieve  their  minds  and  quiet  their  fears.  And 
yet  in  many  cases  we  can  truthfully  affirm  that  if  a  certain  line  of  con- 
duct be  pursued,  health  and  well-being  will  almost  surely  follow.  There 
need  be  no  reasonable  basis  for  the  fear  that  physical  disability  will 
surely  follow,  or  that  death  sooner  or  later,  before  their  life's  work  is 
half  accomplished,  is  certain  to  come. 

Exercise  in  moderation  in  chronic  heart  disease  is  ordinarily  useful ; 
so  long  as  it  does  not  cause  dyspnoea  or  palpitations  it  may  be  indulged 


38  ORGANIC    DISEASE    OF    THE    HEART. 

in  with  advantage  to  the  patient.  While  this  is  true,  it  is  important  to 
emphasize  the  fact  that  all  undue  strain  should  be  carefully  avoided,  as 
harm  will  rapidly  result  whenever  the  heart  is  in  this  manner  unduly 
taxed.  According  to  Oertel,  no  system  is  more  valuable  at  times  in  pro- 
ducing curative  effects  than  that  which  he  lauds  specially.  This  method 
consists  essentially  in  making  the  patient  take  daily  walks  up  declivities 
of  different  steepness.  The  exercise  is  thus  graduated  according  to  the 
requirements  of  the  patient.  There  is  little  doubt  that  when  this  plan 
is  persistently  followed  for  a  certain  length  of  time  favorable  results 
are  frequently  shown.  On  the  other  hand,  some  patients  do  not  appear 
to  be  benefited  at  all  by  these  graduated  exercises.  The  amount  of  ex- 
ercise which  can  be  profitably  taken  by  different  patients  similarly 
affected  as  regards  their  heart  lesion  varies  greatly.  One  patient,  for 
example,  can  lead  a  very  laborious  life  and  yet  be  unconscious  of  the 
fact  that  he  has  a  chronic  cardiac  ailment  until  he  is  almost  at  the  point 
of  death  ;  another  with  an  affection  of  a  like  kind  will  feel  very  much 
even  a  moderate  amount  of  exertion,  and  will  soon  suffer  if  persisted  in, 
with  notable  dyspnoea  and  other  symptoms  showing  cardiac  distress. 

In  cases  of  children,  it  is  sometimes  difficult  to  determine  to  what 
extent  their  play  and  exercise  should  be  controlled.  Of  course,  if  we 
allow  them  to  join  in  all  out-door  sports,  especially  in  those  where  a  con- 
test of  strength  or  endurance  is  likely  to  occur,  great  risk  is  taken  of 
irremediable  injury  being  done  to  an  organ  already  diseased.  If,  on 
the  other  hand,  we  draw  the  lines  too  closely  and  keep  continually 
watching  and  directing  a  boy  or  girl  with  respect  to  their  ordinary 
games,  we  are  liable  to  irritate  and  annoy  them  unnecessarily,  and  in 
the  end  do  them  more  harm  than  good  by  awakening  ever-present  ner- 
vous agitation  or  else  complete  indifference.  Children  cannot,  as  a  rule, 
be  made  to  look  at  things  in  a  cool,  dispassionate  way,  at  least  for  con- 
tinuous periods,  and  must  be  managed  somewhat  differently,  for  this 
reason,  from  adults.  The  true  course,  in  my  judgment,  is  simply  to  for- 
bid absolutely  certain  sports,  such  as  foot-ball,  rowing  races,  tennis  con- 
tests, etc.,  and  to  permit  walking,  riding,  driving,  fishing,  etc.,  which  do 
not  specially  strain  the  heart  or  call  upon  the  energies  to  an  excessive 
degree. 

As  regards  the  dietary,  of  course  individual  idiosyncrasy  is  to  be  con- 
sidered, and  mainly  because  I  have  found  so  many  differences  in  indi- 
viduals as  to  what  kind  of  food  suited  them  best ;  and  yet  we  must  in 
general  insist  upon  what  is  wholesome  ;  viz.,  roast  and  broiled  meats,  no 
rich  sauces,  condiments,  or  made  dishes.  The  ordinary  fresh  vegetables 
may  be  allowed,  avoiding  as  far  as  possible  those  that  are  canned.  Pota- 
toes are  often  injurious,  as  they  produce  flatus  and  are  difficult  of  diges- 
tion. Alcohol  is  bad  in  anything  but  a  limited  amount.  It  may  be 
given  in  moderation  at  meal-time  to  stimulate  appetite  or  promote  diges- 


ORGANIC    DISEASE    OF    THE     HEART.  39 

tion  ;  more  than  this  will  probably  occasion  some  gastric  catarrh,  which 
is  decidedly  prejudicial  by  injuring  the  powers  of  assimilation.  Tobacco 
should  be  avoided,  as  a  rule,  as  it  is  so  apt  to  render  the  heart  irritable 
and  produce  palpitation  and  cardiac  distress.  Very  rarely  in  ray  ex- 
perience has  it  been  evidently  useful;  when  it  is  advantageous  it  seems 
to  be  in  individuals  of  somewhat  plethoric  habit  and  highly  nervous 
organization,  where  it  quiets  and  soothes  nervous  erythism.  Even 
then,  the  tobacco  should  be  of  the  mildest  quality,  and  smoking 
should  only  be  indulged  once  a  day  and  after  meals,  particularly 
dinner.  At  other  times,  tobacco  may  be  said  to  be  almost  invariably 
injurious.  Tea  and  coffee  are  also  to  be  taken  in  small  quantities  and 
not  too  often ;  either  of  these  may  be  allowed  at  breakfast  according  to 
the  taste  and  habit  of  the  individual.  After-dinner  coffee  or  tea  should 
not  be  taken,  as  they  often  disturb  a  night's  rest,  and  thus  bring  on  a 
condition  of  bodily  discomfort  which  is  nowise  compensated  for  by 
the  temporary  exhilaration  which  is  felt  after  their  use. 

I  object,  as  a  rule,  to  cold  baths  for  those  who  suffer  from  heart  dis- 
ease, as  I  find  they  are  apt  to  cause  functional  disturbance;  still  there 
is  positive  good  sometimes  in  having  slight  cutaneous  reaction  after  the 
bath,  which  can  only  follow  where  there  has  been  a  slight  shock  at  first. 
This  shock  ought  not  to  be  marked,  but  only  enough  to  make  the  patient 
feel  brighter  and  more  elastic  after  the  bath  than  previous  to  it.  When- 
ever even  this  small  amount  of  cutaneous  stimulation  is  followed  later 
by  uneasy  precordial  cool  sensations,  baths  should  be  intermitted,  and 
only  tepid  or  warm  baths  taken  every  morning.  Sometimes  it  is  prefer- 
able to  order  the  bath  to  be  taken  at  bedtime,  as  it  promotes  sleep  and 
quiets  restlessness.  In  regard  to  the  preferable  time  of  day,  we  must 
learn  which  is  best  by  trials,  as  I  have  found  that  individual  preferences 
must  be  considered.  It  is  sometimes  more  judicious  to  allow  a  bath 
only  every  other  day,  as  the  daily  bath  seems  to  weaken  the  patient,  and 
he  is  notably  less  active  when  it  is  too  frequently  taken.  For  this 
reason  I  am  inclined  to  recommend  sponge  baths,  rather  than  full  tub- 
baths,  as  the  former  excite  somewhat  nervous  force,  while  the  tub-baths 
are  relaxing  and  seem  in  some  cases,  at  least,  to  lessen  vitality.  Hot- 
water  baths,  hot-vapor  baths,  or  Turkish  baths,  are  all  to  be  studiously 
avoided.  The  risk  from  them  is  very  great,  especially  in  regard  to 
cerebral  hemorrhage.  There  are  times,  of  course,  when  it  is  essential  to 
promote  diaphoresis  in  this  manner.  When  this  is  the  case  and  a  hot- 
air  bath  is  given,  the  head  should  remain  outside  the  hot  air,  so  that 
respiration  may  be  freely  carried  on.  Cold  applications  should  also  be 
made  frequently  or  constantly  to  the  head  during  the  time  of  the  bath, 
so  as  to  lessen  any  tendency  there  may  be  to  cerebral  congestion. 

In  general  terms,  clothing  must  be  suited  to  climatic  conditions,  and 
woollen  or  merino  undergarments  should  be  worn.     This  instruction  to 


40  ORGANIC    DISEASE    OF    THE    HEART. 

wear  flannel  next  to  the  skin  is  very  important  in  cardiac  disease,  as  such 
patients  are  peculiarly  sensitive  to  changes  of  temperature,  and  their 
bodily  heat  is  often  at  a  low  figure.  Moreover,  the  slightest  chill  may 
cause  a  bronchial  attack,  which,  if  at  all  severe,  may  become  very 
threatening,  even  to  life.  It  is  preferable  to  have  the  underwear  light 
in  weight,  as  well  as  warm,  otherwise  the  patient  is  often  oppressed 
and  rendered  uncomfortable.  I  have  known  such  patients  from  wear- 
ing too  heavy  flannels  to  be  at  times  in  a  profuse  perspiration,  which 
of  itself  is  weakening  and  renders  them  liable  to  contract  numerous 
acute  diseases  which  may  at  any  moment  become  complications  of  a 
grave  nature.  Some  authors  advise  against  heavy  overcoats,  which 
oppress  by  their  weight.  My  judgment  is  that  with  our  mode  of  living 
and  changeable,  uncertain  climate,  the  only  wise  plan  for  patients  with 
cardiac  disease  to  follow  is  to  have  outer  garments  of  different  weight 
and  texture,  which  they  can  change  easily  and  according  to  temperature, 
dampness,  and  direction  from  which  the  wind  blows.  One  thing  must 
be  constantly  kept  before  one's  mind,  viz.,  that  these  patients  often  radi- 
ate a  small  amount  of  heat  relatively,  and  this  deficit  must  be  supplied 
by  extra  covering.  Their  circulation  is  deficient,  and  this  is  shown  by 
the  lower  bodily  temperature,  particularly  of  the  extremities,  which 
are  often  cyanosed,  cold,  and  clammy.  The  patients  in  cold  weather 
and  at  night  will  suffer  very  much  from  cold.  No  matter  how  many 
bed-clothes  we  may  cover  them  with,  they  complain  for  quite  a  length 
of  time  of  inability  to  get  warm.  I  know  of  no  means,  indeed,  of  re- 
storing bodily  heat  as  effectually  as  to  put  hot  bottles  to  their  feet  or  to 
either  side  of  the  trunk. 

These  patients  should  lead  placid,  quiet  lives,  free  from  mental  worry 
and  anxieties.  All  emotional  excitements  are  bad.  Not  only  will  sud- 
den or  prolonged  mental  strain  greatly  exaggerate  the  previous  cardiac 
condition  and  render  the  prognosis  graver ;  it  will  of  itself  at  times  oc- 
casion evident  heart  disease.  Such  instances  are  numerous  and  accurately 
recorded.  In  time  of  war,  particularly,  they  have  been  carefully  noted 
and  studied.  In  our  own  country  during  and  subsequent  to  the  War  of 
the  Rebellion  numerous  cases  of  heart  disease  were  described.  It  is  an 
undoubted  fact  that  the  mental  disquietude  which  existed,  particularly 
among  raw  recruits,  was  an  efficient  cause  of  heart  disease.  Da  Costa 
has  placed  on  record  these  cases  with  great  precision  of  detail  and  with 
broad  appreciation  of  the  causation  and  treatment. 

Most  authors  of  works  or  articles  on  organic  heart  disease  refer  also 
to  similar  instances  which  occurred  during  the  terrible  days  of  the 
French  Revolution  at  the  time  of  the  reign  of  terror  in  Paris  and  the 
provinces. 

Constipation  must  be  attended  to  ;  and  even  though  the  bowels  move 
regularly,  an  occasional  purgative  dose  will  help  relieve  the  first  appear- 


ORGANIC     DISEASE    OF    THE    HEART.  41 

ance  of  nervous  congestion  of  the  different  internal  organs  in  an  effective 
manner.  The  sort  of  purgative  dose  to  be  used  is  often  an  indifferent 
matter.  A  little  Hunyadi  or  Friedrichshall  water  once  or  twice  a  week 
in  the  morning  is  frequently  the  simplest  and  easiest  way  of  meeting  the 
indication.  With  those  who  have  a  marked  bilious  tendency,  a  dose  of 
calomel  and  soda,  followed  in  a  few  hours  by  a  draught  with  Rochelle 
salts,  seems  to  give  the  patient  new  life  after  a  few  copious  alvine  dis- 
charges have  carried  out  the  system  a  mass  of  effete  and  waste  mate- 
rial which  was  a  mere  source  of  obstruction  to  the  satisfactory  working 
of  the  different  organs  of  the  body. 

Whenever  the  patient  is  pale,  or  his  appetite  is  poor,  it  is  indicated  to 
give  small  doses  of  the  simple  bitters  before  meals,  combined  or  not  with 
a  mineral  acid.  If  the  patient  be  a  young  person,  one  of  the  iron 
preparations  is  often  useful.  Of  these,  the  choice  may  be  considerable : 
The  tincture  of  iron  agrees  with  many  remarkably  well,  and  except  for 
its  disastrous  effects  upon  the  teeth  should  be  usually  ordered  when  an 
iron  preparation  is  indicated.  As  it  is,  I  avoid  giving  it  unless  there  is 
some  very  special  indication  for  its  use,  and  much  prefer  either  dialyzed 
iron  when  the  stomach  is  peculiarly  sensitive,  or  pills  of  the  proto- 
chloride  of  iron  under  other  circumstances. 

Prior  to  the  use  of  the  iron  salts,  it  is  essential  to  get  the  stomach  and 
digestive  tract  in  proper  shape.  If  there  be  any  evidence  of  catarrhal 
inflammation  of  the  gastro-intestinal  tract,  a  recurrence  for  a  few  days 
to  some  agreeable  saline  mixture  in  the  morning  will  enable  us  to  get 
obvious  and  useful  effects  from  the  preparations  of  iron. 

It  is  thought  by  some  writers  that  iron  should  not  be  given,  ordinarily, 
to  people  of  middle  life  or  advanced  in  years,  even  when  their  blood  is 
poor  in  quality  and  diminished  in  volume.  Arsenic  is  at  times  a  suita- 
ble remedy,  and  will  frequently  be  of  great  benefit  in  helping  impaired 
nutrition.  It  may  be  given  as  arsenious  acid  in  tablet  form,  or  in  solu- 
tion, as  we  have  it  in  Pearson's  or  Fowler's  preparations.  Moderate 
doses  only  should  be  given  daily,  and  after  a  few  weeks  this  medicine 
should  be  interrupted,  either  to  resume  it  later,  or  else  to  try  some  other 
medicine,  with  a  view  to  giving  tone  to  the  patient  who  shows  indica- 
tions of  impaired  vigor. 

Many  occurrences,  doubtless,  of  one's  ordinary  life,  help  disturb  car- 
diac compensation  when  it  exists,  and  it  is  difficult  with  the  wear  and 
tear  of  pressing  occupation  or  interests,  which  can  neither  be  ignored 
nor  gotten  rid  of  by  many  persons  thus  affected,  to  follow  out  the  strict 
medical  indications  in  each  and  every  case  that  is  brought  to  our  atten- 
tion. Yet  when  we  insist  emphatically  how  important  it  is  in  order  to 
retain  a  fair  degree  of  bodily  comfort  to  banish,  as  far  as  may  be  from 
our  ordinary  vocations,  mental  worry  and  bodily  strain,  we  have  done 
much  toward  carrying  home  the   importance   of  the   pernicious   influ- 

4 


42  ORGANIC    DISEASE    OF    THE    HEART. 

ences  when  they  are  allowed  to  exert  themselves.  It  is  also  true  that 
pure  air,  good  food,  gentle  exercise,  hygienic  surroundings  in  what  per- 
tains to  plumbing,  drainage,  and  ventilation,  are  all  important  adjuncts 
to  continuous  well-being  of  very  many  persons  similarly  affected. 

The  compensation  in  organic  heart  disease  is  sometimes  broken  sud- 
denly, and  in  that  case  alarming  symptoms  may  instantly  arise.  These 
instances  are  not  infrequent  after  great  exertions  in  lifting  heavy 
weights,  or  after  severe  contests  in  athletics,  where  the  muscular  and 
nervous  system  has  been  put  on  a  severe  strain  for  several  hours,  or 
even  days'  duration.  After  such  accidental  occurrences  we  are  often 
called  to  witness  and  care  for  the  evidences  of  acute  dilatation  of  the 
heart,  grafted  on  previous  existing  disease.  In  many  instances  the 
effort  or  strain,  whether  it  be  interrupted  or  continuous,  may  seem  in- 
sufficient almost  to  account  for  the  distressing  sequelse  which  follow. 
Yet  when  we  bear  in  mind  the  fact  of  the  pre-existing  state,  we  have 
less  reason  to  be  surprised  than  we  otherwise  would.  Under  like  circum 
stances,  or  even  when  the  patient  was  doing  nothing  unusual  but  merely 
taking  his  ordinary  exercise,  plugging  of  the  coronary  artery  has  oc- 
curred and  brought  on  a  rapidly  fatal  termination. 

The  lack  of  compensatory  power  in  the  heart  may  not  be  of  necessity 
rapid  in  its  occurrence.  Very  frequently  it  comes  on  little  by  little,  and 
in  such  a  manner  that  its  precise  initial  period  is  doubtful.  The  first 
symptoms  of  moment  may  be  cardiac  palpitations,  more  or  less  distress- 
ing in  character,  and  lasting  at  first  but  a  short  time,  which  manifests 
itself  even  after  slight  exertion.  These  patients  often  get  along  very 
comfortably  when  they  walk  on  level  ground,  but  let  them  try  to  go  up 
a  flight  of  stairs,  or  a  steep  declivity  of  any  kind,  and  immediately  they 
suffer  extremely  from  irregular  and  throbbing  heart  pulsations.  Over- 
fatigue, a  high  wind,  late  hours,  emotional  strain  will  cause  similar  un- 
pleasant cardiac  fluttering,  with  choking  sensations  in  the  throat  and 
chest,  and  a  thirst  for  air,  which  is  so  distressing  at  times.  One  of  the 
most  unpleasant  forms  of  this  cardiac  incompetency  is  that  in  which 
nocturnal  dyspnoea  is  the  acute  evidence  of  it.  The  patient  goes  to  bed 
comfortably  and  falls  asleep.  For  several  hours  he  is  obviously  at  ease, 
and  his  slumber  is  restful,  when  suddenly  he  awakens  with  a  start,  in 
great  mental  agitation,  and  his  heart  beats  are  rapid,  irregular,  and 
lacking  in  force.  An  alcoholic  and  ethereal  stimulant  internally  with 
warmth  to  the  chest  by  means  of  a  hot- water  bag  or  poultice  will  in  a 
brief  period  relieve  the  situation  immensely  and  restore  the  patient  to 
relative  ease  and  comfort.  Of  course,  one  must  be  on  guard  in  any 
condition  which  seems  at  first  to  show  cardiac  incompetency  ;  not  to  be 
deceived  as  to  the  cause  of  it. 

An  acute  attack  of  stomachal  dyspepsia  after  a  late  supper,  flatus  with 
distention  of  the  colon  from  persistent  irregularities    of   dietary,  may 


ORGANIC    DISEASE    OF    THE     HEART.  4-'i 

cause  a  flatulent  distention  of  these  organs  which  may  interfere  very 
much  with  the  proper  action  of  the  heart  through  pressure  or  displace- 
ment thus  occasioned,  and  very  great  and  immediate  relief  may  be 
afforded  with  aromatic  stimulants. 

In  affections  of  the  mitral  orifice  mere  irregularity  of  the  pulse  is  so 
frequent  a  sign  of  this  lesion  that  little  importance  should  be  attributed 
to  its  presence,  unless  it  be  allied  with  other  rational  symptoms,  such  as 
dyspnoea,  or  precordial  pain — of  cardiac  insufficiency. 

If  there  be  a  constipated  condition  of  the  bowels,  a  dose  of  licorice 
powder  at  bedtime,  or  a  saline  purge  with  some  carminative  added,  in 
the  morning  on  rising,  may  be  all  that  is  needed  to  re-establish  perfect 
comfort.  If  the  symptoms  of  cardiac  inadequacy  continue  despite  the 
rational  treatment  just  indicated,  and  without  further  trials  of  other 
medication,  absolute  rest  in  bed  must  be  enjoined.  In  a  very  short 
time,  from  this  enforced  quiet  alone,  great  benefit  results  very  often. 
The  compensatory  power  of  the  heart  is  rapidly  re-established,  and  car- 
diac irregularity  may  soon  completely  disappear.  Even  in  those  cases 
where  percussion  shows  pronounced  dilatation  with  enlargement  of  all 
the  cardiac  cavities,  and  there  are  evidences  of  cellular  infiltration  in 
the  lower  limbs,  the  advantages  of  rest  are  unmistakable.  The  rest  in 
bed  is  of  service  mainly  because  the  heart  has  much  less  work  to  do 
when  a  patient  is  in  repose  than  when  he  is  moving  about  actively 
Many  thousand  cardiac  beats  are  thus  prevented  each  day,  and  the  car- 
diac ganglia  have  an  opportunity  to  regain  their  former  power.  Thus, 
the  heart  muscle  is  restored  from  its  fatigued  or  exhausted  condition  and 
proper  rhythmic  explosions  are  developed. 

Just  as  rest  is  important,  so  is  more  sleep  to  be  induced,  and  in  this 
way  a  passing  condition  of  incompetency  is  prevented  from  becoming 
permanent.  Of  course,  if  any  complicating  condition  exists  which 
evidently  interferes  with  the  patient's  rapid  recuperation,  this  should  be 
properly  attended  to.  Among  these  we  would  mention  mal-assimila- 
tion  of  food,  leucorrhoea,  diarrhoea,  bleeding  piles.  The  mere  fact  of 
arresting  a  weakening  discharge  by  administering  proper  medicinal 
remedies,  in  connection  with  an  appropriate  dietary,  may  be  of  great 
service  in  promoting  the  cure,  or  great  relief  of  the  case,  so  far  as  all 
functional  disturbance  is  concerned.  Such  remarkable  effects  are  so 
frequently  obtained  by  attention  to  the  foregoing  indications  that  patients 
are  apt  to  become  reckless  and  the  physician  careless.  The  result  is 
that  frequently  the  patients  go  back  too  soon  to  the  mode  of  life  which 
has  been  the  direct  occasion  of  their  bad  symptoms,  and  very  soon  we 
have  a  return  of  the  latter  in  an  aggravated  form. 

Whenever  the  case  is  that  of  a  workingman  or  woman,  they  should 
be  particularly  warned  against  the  evil  effects  of  sudden  strains  on  the 
heart,  and  should  be  told  to  seek,  if  necessary,  occupations  in  which  the 


44  ORGANIC    DISEASE    OF    THE    HEART. 

hours  of  work  may,  perhaps,  be  longer,  but  the  danger  of  frequent  or 
occasional  occurrence  of  great  efforts  will  be  wholly  avoided.  If  the 
patient  be  a  professional  man  accustomed  to  great  mental  toil  he  should 
be  brought  to  consider  the  necessity  of  an  out-door  life,  longer  hours  of 
sleep,  and  soothing  mental  distractions  as  far  as  is  practicable.  If  the 
patient  be  a  lady  addicted  to  the  pleasures  of  fashionable  entertain- 
ments, where  late  suppers,  dancing,  and  the  great  stress  of  this  mode  of 
life  in  lessening  nerve  force  be  the  custom,  she  must  be  told  emphatically 
that  it  is  only  by  abandoning  these  pleasures  that  she  can  be  restored  to 
health,  and  that  the  heart  can  recover  healthy  action  in  proportion  as 
the  structural  failure  may  be  lessened  or  cured — i.  e.,  cardiac  dilatation. 

In  many  cases,  however,  progress  of  organic  disease,  although  pre- 
vented for  a  longer  or  shorter  period,  is  steadily  worse.  Onward  and 
downward  is  the  march  of  events.  Under  these  circumstances  we  are 
obliged  to  depend  upon  drugs  or  other  medication  systematically  used 
from  time  to  time,  or  continuously,  to  obtain  an  arrest  of  the  troublous 
effects  of  disease. 

The  remedies  employed  are,  first,  those  which  stimulate  the  heart- 
action  ;  and  second,  those  which  are  directly  tonic  or  corroborant  in  their 
effects,  not  only  to  the  heart,  but  also  to  the  blood  and  general  system 
as  well.  Digitalis  easily  ranks  first  among  the  former  in  the  estima- 
tion of  the  great  number  of  clinicians,  and  must  be  given  without  regard 
to  the  nature  of  the  lesion  whenever  the  heart  begins  to  fail  and  is 
unrelieved  by  the  means  previously  referred  to.  Digitalis  unquestion- 
ably, in  the  great  majority  of  cases,  leads  other  remedies  by  the  certainty 
of  its  power  and  action.  Whenever  digitalis  in  small  or  moderate  doses 
remains  without  apparent  good  effect,  and  the  patient  is  evidently  ansemic 
and  has  not  yet  reached  middle  life,  some  iron  salt  may  be  combined 
with  it.  There  are  some  instances  in  which  the  iron  and  digitalis  once 
begun,  in  order  to  restore  the  compensatory  balance  in  the  heart  muscle, 
have  to  be  continued  long  periods  of  time  and  almost  continuously. 
In  other  instances  the  treatment  by  digitalis  alone  or  digitalis  and  iron 
combined  are  only  required  occasionally  and  for  a  few  weeks  on  any 
occasion  to  bring  back  the  circulation  to  healthy  activity.  The  effect 
of  digitalis  in  small  doses  persistently  and  constantly  given  for  a  while 
is  to  diminish  markedly  cardiac  dilatation,  whether  there  be  or  not  in- 
sufficiency at  the  mitral  orifice.  Sometimes,  as  an  aid  to  the  digitalis, 
strychnine  may  be  advantageously  combined  with  it.  Strychnine,  besides 
stimulating  the  heart,  is  also  a  stimulant  to  the  respiratory  centres,  and 
this  action  is  often  valuable  in  view  of  the  relations  between  the  circu- 
lation and  respiration,  independently  of  what  is  simply  mechanical. 

It  is  sometimes  wise  if  there  be  a  chronic  lung  affection,  as  cirrhosis 
or  emphysema,  at  the  same  time  that  there  is  notable  cardiac  asthenia, 
to  add  carbonate  of  ammonia  to  the  previous  combination  of  strychnine 


ORGANIC    DISEASE    OF    THE     HEART.  45 

and  digitalis.  Instances  are  not  rare  in  which  some  combination  of  two 
or  more  of  these  drugs  has  been  taken  for  years,  and  when  at  any  time 
they  were  interrupted  almost  immediately  the  patient  began  again  to 
suffer  from  palpitations  or  cardiac  distress. 

No  doubt  in  many  of  these  cases  where  regurgitation  at  the  mitral 
orifice  results  mainly  from  mere  weakness  of  the  cardiac  muscle,  and 
very  little  from  the  valvular  changes,  which  are  very  slight,  the  depend- 
ence of  the  heart  upon  stimulation  from  these  drugs  is  very  great.  Evi- 
dently, as  has  been  shown,  the  mechanism  for  closing  the  mitral  orifice 
does  not  reside  in  the  valve  alone,  but  much  power  is  present  in  the 
muscular  walls  of  the  left  ventricle,  not  only  to  lift  the  valve  itself,  but 
also  to  diminish  the  mitral  orifice. 

As  a  rule,  however,  digitalis  should  be  intermitted  from  time  to  time, 
in  order  to  obtain  its  best  effects.  Once,  indeed,  its  bad  effects  produced, 
such  as  nausea  and  vomiting,  it  is  frequently  with  some  difficulty  that 
we  again  obtain  tolerance  for  the  use  of  the  drug. 

One  of  the  observations  of  Withering,  who  wrote  about  the  use  of 
digitalis  at  the  end  of  the  last  century,  was  that  it  acted  particularly 
well  with  dropsical  patients,  and  when  the  pulse  was  low,  feeble,  irregular, 
or  intermittent ;  on  the  contrary,  when  there  was  a  tense  pulse  with 
evident  thickening  of  the  arterial  coats,  its  action  was  not  so  beneficial 
or  its  diuretic  action  at  all  pronounced.  This  view  of  Withering  is 
practically  somewhat  our  own  estimate  of  digitalis  to-day.  It  is  gener- 
ally admitted  that  it  increases  and  lends  force  to  the  systole  of  the  heart ; 
at  the  same  time,  digitalis  unquestionably  contracts  the  arterioles,  and  it 
is  in  this  manner  that  arterial  tension  is  increased.  This  double  effect 
is,  as  a  rule,  very  useful  in  mitral  regurgitation,  particularly  at  the 
commencement  of  this  disease  and  when  both  effects  of  digitalis  are 
desirable.  Later  on,  the  action  of  digitalis  on  the  arterioles  is  not  so 
satisfactory,  especially  when  dropsy  has  set  in,  because  this  effect  mili- 
tates against  its  diuretic  action,  which  is  so  essential  at  this  period  of  the 
disease.  In  order  to  obviate  as  far  as  possible  this  untoward  action  of 
digitalis,  we  should  exhibit  concomitantly  with  it  moderate  doses  of 
nitroglycerin. 

By  the  use  of  these  drugs  combined  with  one  another  we  can  fre- 
quently accomplish  effects  at  the  terminal  stage  of  a  mitral  lesion  which 
we  can  obtain  in  no  other  manner.  The  action  of  the  nitroglycerin  is 
doubly  useful  under  these  circumstances.  It  adds  to  the  power  of  the 
heart's  contractions;  it  dilates  peripheral  vessels,  and  thus  renders  these 
contractions  more  effective,  and  thus  the  diuretic  action  of  the  digitalis 
is  notably  increased.  The  amount  of  either  one  of  these  drug3  which 
may  be  given  advantageously  in  the  condition  of  obstinate  or  increasing 
dropsy  cannot  easily  be  determined  in  advance.  My  plan  is  to  give, 
say  one  drachm  of  the  infusion  of  digitalis  and  ^^  gr.  of  nitroglycerin 


46  ORGANIC    DISEASE    OF    THE     HEART. 

every  two  hours,  and  progressively  increase  both  of  them,  if  need  be,  up 
to  two  or  three  drachms  of  the  infusion  of  digitalis  every  two  hours,  and 
-5*5-  gr.,  or  even  more,  of  the  nitroglycerin  at  similar  intervals,  before  we 
can  obtain  the  most  desirable  effects.  Everything  depends  upon  the 
case  and  the  effects  of  the  drugs.  If  digitalis  apparently  causes  nausea 
or  vomiting,  if  the  pulse  under  its  influence,  instead  of  becoming  stronger 
and  more  regular,  becomes  weaker,  intermittent,  and  very  slow,  it  is 
time  to  diminish,  or  it  may  be,  interrupt  its  use  for  several  hours  or  days. 
These  indications  are  even  more  formal  whenever  the  quantity  of  urine 
remains  the  same  and  its  density  is  unaltered.  As  regards  the  nitro- 
glycerin, if  the  head  throbs  and  pains  in  a  notable  manner,  whilst  the 
pulse  remains  small,  feeble,  and  uncertain,  to  increase  its  dose  would  be 
of  questionable  utility. 

It  is  most  important  in  the  use  of  these  drugs  to  know  that  their 
quality  and  preparation  can  be  relied  on.  The  tablets  of  nitroglycerin 
as  purchased  in  many  drug  stores  are  frequently  unreliable,  and  we  can 
at  times  use  very  large  doses  of  the  drug  in  this  form  without  obtaining 
the  effects  we  should  expect  from  it  ordinarily.  It  is  preferable,  there- 
fore, to  make  use  of  a  freshly  prepared  solution,  graduated  so  as  to 
exhibit  in  every  teaspoonful  a  given  amount  of  the  active  ingredient. 
The  best  preparation  of  digitalis  cannot  always  be  stated.  Personally, 
I  favor  the  fresh  infusion  of  the  leaves  in  cases  where  I  desire  particu- 
larly to  procure  its  diuretic  action.  In  cases  where  the  tonic  effect  on 
the  heart  is  most  important,  I  prefer  the  tincture.  Moreover,  the  tincture 
is  such  an  available  preparation,  which  we  can  always  obtain  and  keep 
ready  for  immediate  use,  that  this  very  convenience  makes  us,  perhaps, 
somewhat  over-i'ate  its  value.  The  fluid  extract  is,  of  course,  given  in 
smaller  bulk  on  account  of  its  greater  strength.  Further  than  this  I 
do  not  believe  it  has*  any  appreciable  different  value  from  the  tincture, 
as  I  do  not  think  the  addition  of  alcohol  in  the  tincture  makes  any 
essential  change  in  its  action  unless  the  doses  given  be  unusually 
large. 

I  am  confident  that  the  action  of  hydragogue  purgatives  is  very  im- 
portant to  relieve  dropsy,  and  particularly  in  those  cases  where  digitalis 
in  moderate  doses  and  by  itself  has  not  notably  increased  the  bulk  of 
urine.  Compound  jalap  powder,  with  or  without  calomel,  has  always 
seemed  to  me  the  most  reliable  among  the  purgatives,  and  I  give  it 
invariably  almost  the  preference  over  other  means  in  this  line  when 
treatment  is  begun. 

Elaterium  and  croton  oil  never  appear  to  me  desirable  if  they  can  be 
properly  avoided,  or  if  the  compound  jalap  or  scammony  powders  prove 
active  and  beneficial.  After  repeated  movements  from  the  bowels,  which 
follow  the  use  of  these  purgatives,  the  diuretic  action  of  the  digitalis 
and  nitroglycerin  is  shown  frequently  in  a  remarkable  manner,  and 


ORGANIC    DISEASE    OF    THE    HEART.  47 

the  bulk  of  urine  is  increased  from  a  few  ounces  to  several  pints  in  a 
few  days. 

I  have  no  doubt  that  it  is  important  in  these  instances  not  to  attempt 
giving  any  solid  food  by  the  mouth,  for  the  patient  will  be  quite  unable 
to  digest  it,  and  the  only  consequence  of  allowing  it  to  be  taken  is  to 
bring  on  nausea  or  vomiting,  besides  causing  stomachal  distress,  and,  it 
may  be,  further  injuring  the  condition  of  the  patient  by  the  toxins  which 
are  produced  and  absorbed.  The  diet  should  be  a  strictly  fluid  one, 
and  even  the  quantity  of  the  fluid  must  be  limited.  It  would  not  do  to 
allow  a  patient  where  dropsy  is  very  considerable  to  take  large  draughts 
of  milk  or  water.  The  milk  should  be  limited  to  two  or  three  ounces 
every  two  hours,  and  given  preferably  peptonized. 

Unless  the  patient  be  unusually  prostrated  he  should  not  be  awakened 
if  he  is  asleep  to  give  him  his  dose  of  milk.  Of  course,  this  severity  in 
regard  to  the  quantity  of  fluids  allowed  should  only  last  while  the  drop- 
sical condition  is  very  threatening.  As  soon  as  the  vessels  are  able  to 
take  up  the  effused  serum  in  the  tissues  and  cavities,  owing  to  the  drugs 
employed  and  the  dietary  just  insisted  upon,  the  latter  may  be  increased 
or  made  somewhat  more  liberal. 

It  is  especially  important  whenever  the  serous  cavity  contains  fluid, 
either  of  the  chest  or  the  abdomen,  to  let  it  out  by  paracentesis,  or 
otherwise  the  patient's  chances  of  even  temporary  recovery  are  greatly 
diminished.  It  is  sometimes  these  repeated  tappings  which  keep  such 
patients  alive  for  long  periods  and  enable  them  to  get  about  once  more, 
when  without  them  they  would  surely  die,  and  that,  too,  very  rapidly. 
I  can  recall  instances  where  withdrawal  of  chest-fluid  on  repeated  occa- 
sions had  helped  restore  the  patient,  with  the  other  agents  and  care 
insisted  upon,  to  a  state  of  relative  strength  and  comfort  which  has 
lasted  a  considerable  period.  The  same  statement  is  true  in  regard  to 
abdominal  puncture  with  withdrawal  of  intra-peritoneal  effusion. 

Of  course,  if  there  be  dropsy  in  connection  with  aortic  disease  the 
same  treatment  holds  good  ;  but  it  is  a  well-known  fact  that  this  com- 
plication is  then  infrequent,  and  it  is  far  more  probable  to  encounter  it 
with  advanced  mitral  lesions. 

Whenever  the  tricuspid  valves  have  lost  their  ability  to  close  the 
right  auriculo  ventricular  orifice,  and  the  cavity  of  the  ventricle  is  dis- 
tended, while  the  muscular  walls  have  lost  compensatory  power,  we  have 
to  do  with  those  very  bad  cases  in  which  the  prognosis  is  gravest.  With 
pulsating,  enormously  distended,  over-charged  jugulars,  with  markedly 
pronounced  epigastric  pulsations,  and  the  soft  blowing  murmur  distinctly 
marked  over  the  right  heart,  in  addition  to  numerous  other  signs  inci- 
dent to  this  state,  we  have  one  other  means  besides  the  foregoing  which 
will  help  us  sometimes  relieve  our  patient,  at  least  temporarily.  This 
final  expedient  is  blood-letting.     The  vein  at  the  bend  of  the  elbow  must 


48  ORGANIC     DISEASE    OF    THE     HEART. 

be  opened  and  the  blood  allowed  to  escape.  A  few  ounces  thus  taken 
will  sometimes  give  notable  relief  and  enable  the  right  heart  to  continue 
its  beats,  when  without  this  help  it  would  soon  cease  to  combat  the 
increasing  pressure  from  within  from  the  quantity  of  its  contained 
blood. 

It  will  not  answer  in  an  advanced  state  of  incompetency,  where  dis- 
tress and  lack  of  power  are  marked  with  such  intense  features,  to  do 
more  than  afford  some  relief  in  this  way.  If  we  attempt  it  we  are  apt 
to  weaken  the  patient  too  much,  and  the  heart  soon  ceases  to  contract 
altogether,  and  stops  in  diastole.  Of  course,  in  those  cases  where  there 
is  acute  dilatation  of  the  right  cavities  in  a  heart  as  yet  undegenerated, 
and  which  is  but  the  result  of  over-strain,  the  quantity  of  blood  which 
can  be  advantageously  taken  by  venesection  is  sometimes  very  consider- 
able, and  even  as  much  as  a  pint  or  more  will,  be  a  loss  soon  completely 
replaced.  Moreover,  the  patient's  condition  seems  lighter  and  better  in 
every  way  from  getting  rid  of  an  excess  of  blood,  which  was  the  greatest 
obstacle  which  stood  in  the  way  of  possible  recovery  from  animmineutly 
threatening  condition. 

This  indication  for  relief  of  the  right  heart  by  venesection  in  acute 
dilatation  is  not  changed  by  the  fact  that  there  may  be  old  bronchial 
imflammation  with  emphysema  ;  on  the  contrary,  in  just  such  cases  this 
means  may  be  our  most  potent  one  of  saving  life,  and  all  other  meaus 
without  it  appear  at  times  to  be  insufficient  or  unavailing. 

Although  the  usefulness  of  digitalis  has  not  been  doubted  in  later 
years,  at  least,  as  to  its  power  to  combat,  when  properly  managed  and 
helped  in  its  action  by  the  other  means  which  I  have  mentioned,  the 
dropsical  condition  dependent  on  organic  heart  disease,  such  is  not  the 
invariable  opinion  held  about  the  value  of  this  drug  in  aortic  lesions 
where  dropsy  is  present.  Theoretically  it  has  been  considered  injurious, 
because  the  diastole  of  the  heart  was  lengthened,  and  thus  the  disten- 
tion of  the  left  ventricle  was  said  to  be  increased.  Practically,  however, 
this  judgment  cannot  be  regarded  simply  because  after  the  continuous 
use  of  digitalis  for  some  time,  even  in  this  condition,  we  shall  note  in- 
crease in  the  vigor  of  cardiac  contractions.  Moreover,  the  pulse  becomes 
stronger  and  more  regular,  the  dropsy  decreases,  and  the  bulk  of  the 
urine  notably  augments.  It  is  wise,  however,  with  an  aortic  lesion 
present,  never  to  give  large  doses  of  digitalis  in  the  beginning,  and  to 
increase  even  a  very  moderate  dose  of  the  drug  with  great  care  and 
circumspection.  Upon  any  indication  of  its  failing  to  be  beneficial  it 
is  only  prudent  to  withdraw  the  use  of  the  drug  and  substitute  some 
other  cardiac  stimulant  in  its  place. 

Whenever  the  oedema  of  the  lower  limbs  continues,  with  other  evidences 
of  dropsical  effusion,  and  is  not  influenced  by  all  previous  remedies,  we 
are  compelled  to  resort  to  the  use  of  Southey's  tubes  or  to  repeated  scari- 


ORGANIC    DISEASE    OF    THE     HEART.  49 

fications,  with  proper  antiseptic  precautions  to  relieve  their  great  disten- 
tion. Without  such  means  of  relief,  painful  ulcers  may  occur,  which  it 
is  almost  impossible  to  heal,  and  they  render  the  patient's  condition  even 
more  deplorable. 

A  red  blush  over  the  thickened  and  tense  skin,  not  unlike  an  erysipe- 
latous inflammation,  may  occur  and  give  additional  anxiety  in  our 
patient's  behalf.  After  scarification  or  punctures,  and  when  the  fluid 
has  pretty  well  drained  from  the  lower  limbs,  they  should  be  wrapped 
in  canton-flannel  bandages,  which  are  frequently  renewed,  so  as  to  keep 
down  the  recurrence  of  the  great  swelling  and  distention.  These  means 
are  but  temporary  expedients  and  fail  to  afford  more  than  passing  relief. 

According  to  some  writers,  caffein  is  very  little  to  be  relied  upon  in 
the  treatment  of  any  form  of  organic  heart  disease.  This  opinion, 
fortunately,  is  not  general,  and  certainly  does  not  correspond  with  my 
own  experience.  In  doses  of  one  to  three  grains  by  the  mouth,  espe- 
cially in  the  form  of  the  citrate,  by  reason  of  its  solubility,  I  regard  it 
as  being  a  very  excellent  heart  stimulant.  In  my  judgment,  as  in  that 
of  others,  it  is  especially  adapted  to  certain  cases  of  mitral  stenosis  in 
which  dyspnoea  is  excessive  and  where  digitalis  does  not  seem  to  act 
well.  It  is  also  very  desirable  to  make  use  of  citrate  of  caffein  in  com- 
bination with  strychnine  in  cases  of  aortic  incompetence  which  do  not 
respond  favorably  to  the  action  of  digitalis.  Caffein  not  only  agrees 
with  the  stomach  very  well  when  digitalis  disturbs  it  given  in  any  form, 
but  it  likewise  has  a  very  marked  diuretic  action,  particularly  if  the 
kidneys  are  not  much  diseased,  which  may  be  shown,  although  digitalis 
has  remained  inactive  in  this  regard. 

Some  writers  have  regarded  the  citrate  of  caffein  as  inert  when  given 
as  a  salt  already  prepared,  but  in  this  opinion  I  am  inclined  to  believe 
they  are  greatly  mistaken.  Even  in  the  last  stages  of  chronic  heart 
disease,  this  drug  when  given  in  one-grain  doses  hourly  has  been  of 
great  service  after  digitalis  has  failed  to  produce  the  slightest  favorable 
impression  upon  the  patient,  and,  indeed,  has  been  followed  by  many 
evidences  of  intoxication  from  retention  of  the  drug  in  the  economy. 
Whenever  the  powers  of  assimilation  are  very  imperfect,  the  salicylate 
or  benzoate  of  caffein  should  be  employed  hypodermically  by  reason  of 
their  perfect  solubility  and  their  non-irritant  local  effects. 

The  two  objections  to  the  employment  of  caffein  continuously  in  large 
or  frequently  repeated  doses,  are  first,  its  action  in  causing  insomnia, 
which,  of  course,  is  a  great  drawback  when  a  patient's  nervous  system 
seems  to  call  imperatively  for  the  influence  of  this  great  restorer  of 
bodily  comfort.  Again,  I  have  known  patients  to  become  restless  and 
mentally  agitated  to  a  high  degree  when  I  have  persistently  used  caffein 
for  several  days  continuously  with  but  short  intervals  of  rest  between 
doses.     Hallucinations  and  delirium  have  occurred  when  a  nearly  poison- 


50  ORGANIC    DISEASE    OF    THE    HEART. 

ous  dose  has  been  taken  by  mistake  rather  than  premeditation.  The 
objectionable  fact  of  these  occurrences  has  been  insisted  upon  by  some 
writers. 

There  is  another  remedy  for  failing  heart  about  whose  value  there 
seems  to  be  just  as  much  difference  of  opinion  as  there  is  in  regard  to 
caffein,  and  that  is  convallaria  majalis.  The  Russians  and  some  distin- 
guished observers  in  France  and  England  consider  it  to  be  eminently 
valuable.  It  has  been  said  to  produce  evident  regularity  of  the  pulse 
and  increased  force  of  heart-beats,  with  great  diuretic  power  in  cases 
even  where  there  was  marked  tricuspid  regurgitation.  And  this  action 
may  be  noted  after  digitalis  fails.  Like  caffein,  convallaria  does  not 
impair  stomachal  digestion,  but  is  easily  tolerated  ;  associated  or  not 
with  caffein,  it  seems  well  adapted  to  cases  of  mitral  stenosis.  It  may 
be  given  as  the  tincture  or  fluid  extract.  I  have  prescribed  the  drug 
repeatedly  for  many  years,  and  have  been  much  pleased  with  its  action 
on  several  occasions  when  I  was  really  despairing  as  to  what  could  be 
done  to  afford  relief  to  a  water-logged  patient. 

In  mitral  stenosis,  the  difficulty  against  which  we  are  obliged  to  con- 
tend is  not  the  dilated  left  ventricle,  to  which  we  wish  to  give  strength 
and  tenacity,  but  it  is  the  tendency  to  pulmonary  congestion,  which  throws 
more  work  on  the  right  heart.  If  we  attempt  to  increase  the  vigor  of 
the  right-heart  contractions  with  the  use  of  digitalis,  while  the  lungs  re- 
main congested  owing  to  the  fact  of  the  non-passage  of  a  sufficient  quan- 
tity of  blood  through  a  much  narrowed  mitral  orifice  in  a  certain  length 
of  time,  the  patient's  distress  is  not  relieved,  but  the  dyspnoea  from 
which  he  is  suffering  is  frequently  much  increased.  Aconite  in  small 
repeated  doses  is  said  occasionally  to  be  of  service  under  these  conditions. 
I  have  never  believed  this  observation  to  be  correct,  at  least  among 
adults ;  but,  on  the  contrary,  am  of  the  opinion  that  the  use  of  this  drug 
merely  aggravates  the  preceding  condition  by  increasing  vascular  par- 
alysis in  the  lungs.  A  far  better  method  is  to  use  repeated  doses  of 
nitroglycerin  in  all  urgent  cases  and  whenever  the  patient  has  been  un- 
relieved by  caffein  and  convallaria,  and  afterward  to  follow  up  the  use 
of  nitroglycerin  by  the  long-continued  exhibition  of  strychnine  or  nux 
vomica. 

^It  has  always  appeared  to  me  highly  injudicious  to  make  use  of  aconite 
in  any  appreciable  dose  in  the  treatment  of  any  condition  of  failing 
heart  strength,  acute  or  chronic,  particularly  among  adults.  With 
children  I  am  occasionally  of  a  different  opinion  ;  but  even  such  instances 
are  rare  in  practice,  and  unless  a  child  has  a  febrile  state  concomitant 
with  the  intracardiac  condition,  and  which  is  apparently  of  ephemeral 
nature  and  without  evident  localization,  I  am  loath  even  with  them  to 
give  aconite,  except  in  very  small  doses. 

In  certain  cases  of  cardiac  hypertrophy  connected   with  or  indepen- 


ORGANIC    DISEASE    OF    THE    HEART,  51 

dent  of  a  valvular  lesion,  aconite  has  been  used  by  many  practitioners 
with,  as  they  believe,  obvious  benefit.  The  cases  where  this  action  seems 
most  desirable  are  those  in  which  the  cardiac  impulse  is  excessive  and 
the  patient  is  annoyed  with  the  throbbing  and  pulsation  in  the  chest, 
which  apparently  indicate  excessive  cardiac  action.  It  is  probable  that 
this  excessive  action  rarely  occurs,  and  we  should  be  very  careful,  in  my 
judgment,  of  toning  down  the  heart.  If  we  must  give  a  cardiac  seda- 
tive, I  attach  far  more  value  to  the  use  of  the  mixed  bromides  than  I 
do  to  aconite. 

Of  the  bromides,  I  regard  the  salt  of  sodium  as  least  likely  to  do 
harm,  and  I  am  sure  that  I  have  often  given  this  remedy  in  large  doses, 
3SS-3J,  several  times  in  the  twenty-four  hours,  without  occasioning  any 
cardiac  depression.  On  the  contrary,  it  has  seemed  to  exercise  a  gentle, 
soothing,  and  quieting  effect,  which  diminished  the  turbulent  action  of 
the  heart  without  lessening  its  strength. 

What  is  true  of  the  bromides  is  also  true  of  the  valerianates — and 
valerianate  of  ammonia  in  pill  form  is  a  most  valuable  adjunct  to  our 
treatment  in  these  cases.  The  excessive  cardiac  action  may  be  attended 
with  feelings  of  fulness  or  uncertainty  in  the  head,  and  the  tinnitus 
aurium  from  which  such  patients  occasionally  suffer  is  extremely  annoy- 
ing and  objectionable.  I  have  known  these  unpleasant  sensations  to  be 
greatly  diminished  by  salicylate  of  soda,  with  a  small  addition  of  phe- 
nacetine.  Of  course,  the  use  of  the  latter  prescription  should  simply  be 
made  while  the  aural  and  head  symptoms  are  actually  a  source  of  great 
discomfort.     As  soon  as  they  are  dissipated  we  should  interrupt  their  use. 

In  cardiac  hypertrophy,  as  long  as  tension  is  kept  up  in  the  arteries, 
the  prognosis  is  good,  because  we  know  that  the  general  and  cardiac 
nutrition  are  being  sustained.  Whenever  this  tension  fails,  by  reason  of 
the  rupture  or  of  the  insufficiency  of  one  of  the  coronary  cups,  we  know 
that  the  prognosis  has  become  serious,  and  that  the  case  will  progress 
rapidly  downward.  Even  under  these  conditions,  we  have  tumultuous 
intrathoracic  throbbings,  but  they  show  not  strength  but  weakness,  and 
that  weakness  is  of  secondary  degeneration,  against  which  we  should  fight, 
not  with  depressant  agents  like  aconite  and  veratrum  viride,  but  rather 
with  heart  tonics,  like  strychnine  and  iron,  which  in  restoring  vigor  to 
the  heart-muscle,  lessen  its  impotent  struggle,  as  shown  by  the  dissipation 
of  painful  symptoms,  which  from  a  narrow  and  limited  observation,  ap- 
pear to  indicate  nerve  sedatives. 

Whenever  cardiac  power  is  defective  there  is  an  insufficient  quantity 
of  blood  sent  out  by  its  pulsations  to  the  arteries  which  distribute  them- 
selves throughout  the  body.  Owing  to  this  insufficient  distribution  of 
arterial  blood  there  is  a  marked  tendency  to  venous  engorgement  every- 
where. In  the  kidneys  we  have  it,  and  albuminuria  follows ;  in  the 
stomach  it  is  evident,  and  gastric  catarrh  results ;  in  the  liver  the  venous 


52  ORGANIC    DISEASE    OF    THE     HEART. 

portal  circulation  is  clogged,  and  soon  the  sclerotics  are  yellow,  the 
tongue  coated,  and  nausea  and  inappetence  present  themselves.  With 
this  marked,  recurring,  or  almost  constant  venous  engorgement  of  the 
viscera,  fibrous  changes  occur  in  all  these  organs,  and  these  permanent 
changes  weaken  and  cripple  them  in  their  functional  power  to  that  degree 
finally  that  no  remedies  can  ultimately  afford  relief,  even  to  symptomatic 
disturbance. 

Whenever  in  the  conditions  alluded  to  we  have  called  to  our  help 
the  power  of  digitalis,  and  instead  of  giving  notable  relief,  it  merely 
diminishes  the  pulse-rate  so  as  to  make  it  abnormally  slow,  we  should 
abandon  its  use  and  recur  to  that  of  the  other  cardiac  stimulants.  When 
we  are  assured  that  we  have  obtained  good  results  we  note  easily  a 
stronger  heart-beat,  an  increased  pulse  tension,  and  a  real  compensatory 
hypertrophy.  Doubtless,  at  the  same  time,  the  coronary  arteries  are 
filled  with  blood,  the  nutrition  of  the  heart  is  improved,  and  the  arterial 
recoil  accentuated. 

One  of  the  bugbears  of  many  practitioners  relates  to  the  so-called 
cumulative  action  of  digitalis.  As  a  fact,  there  is  no  more  danger  of  this 
with  digitalis  than  there  would  be  in  the  case  of  many  other  heart  tonics, 
if  they  were  injudiciously  managed,  as  is  true  whenever  digitalis  is  followed 
by  sudden  poisonous  effects  of  marked  severity.  Digitalis  does  not  elimi- 
nate itself  from  the  economy  rapidly  ;  and,  of  course,  if  we  give  large 
dose3  of  it  in  short  periods  of  time  we  may  get  untoward  effects,  just  as 
we  might  if  we  gave  arsenic  or  belladonna  frequently,  and  without  allow- 
ing time  enough  for  their  physiological  elimination  from  the  body.  I 
must  protest,  however,  against  the  notion  still  common  with  some  prac- 
titioners, that  digitalis  has  a  way  of  its  own  of  lying  dormant  for  a  while, 
and  afterward  appearing  suddenly,  and  springing,  as  it  were,  upon  the 
poor  victim,  who  will  show  signs  of  poisoning  from  its  use.  This  idea  is 
very  erroneous,  and  should  be  combated  forcibly  whenever  it  appears. 
Of  course,  in  certain  forms  of  heart  disease  but  for  mechanical  reasons, 
as  in  hypertrophy,  we  should  be  very  temperate  in  our  use  of  digitalis, 
or  else  we  would  do  great  damage.  On  the  other  hand,  in  cardiac  dila- 
tation it  is  more  than  doubtful  whether  we  could  really  poison  an  indi- 
vidual with  this  drug  unless  we  gave  excessive,  almost  unjustifiable,  doses. 
Even  in  cardiac  dilatation,  however,  the  use  of  digitalis  must  be  inter- 
mitted when  we  have  obtained  desirable  effects,  or  else  we  may  occasion 
a  return  of  cardiac  palpitation  and  irregularity  of  the  heart.  Sometimes, 
with  the  presence  of  cardiac  dilatation,  we  may  have  a  cardiac  systolic 
murmur  at  the  apex,  and  after  digitalis  has  been  taken  for  a  while  the 
murmur  disappears.  This  simply  means  that  the  cardiac  ostium  has 
become  smaller  through  ventricular  contraction  so  as  to  permit  the 
valve  to  be  competent  once  more.  Again,  sometimes,  a  murmur  which 
did  not  exist  at  first,  with  evidences  of  cardiac  dilatation,  may  become 


ORGANIC     DISEASE    OF    THE    HEART.  53 

distinct  after  the  continuous  use  of  moderate  doses  of  digitalis,  and  yet 
all  the  rational  symptoms  of  cardiac  incompetence  previously  observed 
by  the  patient  have  greatly  improved  or  entirely  disappeared.  This 
means  merely  that  the  heart  has  obtained  renewed  power,  that  the  mus- 
cular contraction  of  the  heart-walls  is  greater,  and  that  the  blood  when 
thrown  through  the  enlarged  or  diseased  orifice  gives  a  murmur  which 
was  not  noticed  previously,  because  the  heart  had  not  force  sufficient  to 
produce  it.  The  ventricle  in  the  latter  case  also  may  show  signs  of 
diminution  as  to  volume  as  well  as  increased  force  in  its  dynamic 
function. 

There  are  many  states  of  cardiac  asthenia,  as  those  resulting  from 
effort  or  great  and  sudden  shock,  in  which  it  is  nearly  impossible  to 
recognize  at  once,  or  indeed,  until  the  patient  has  been  carefully  ob- 
served for  several  days  or  weeks,  what  amount  of  disturbance  is  purely 
functional  and  what  amount  is  occasioned  by  organic  heart  changes. 
Murmurs,  intermittences,  cardiac  irregularities,  combined  with  weakness 
of  heart  action,  afford,  at  least,  sufficient  reasons  to  be  doubtful  as  to  the 
r6le  each  may  play  in  the  condition  presented  to  us.  Careful  physical 
examination  will  not  invariably  enable  us  accurately  to  determine  the 
size  or  precise  state  of  the  heart,  owing  perhaps  to  the  corpulency  of  the 
individual,  to  intra-pulmonary  conditions,  to  natural  conformations  of 
the  chest- walls,  to  organic  or  functional  disease  of  one  or  more  of  the 
abdominal  viscera.  When  we  are  in  reasonable  doubt  as  to  our  diag- 
nosis we  should  treat  the  case  very  much  as  we  would  if  we  were  quite 
confident  we  had  to  do  with  cardiac  insufficiency  depending  solely  on 
organic  heart  disease.  In  fatty  degeneration  of  the  heart  the  cardiac 
stimulants  are  often  necessary  in  order  to  increase  rhythmic  action 
through  their  influence  on  the  intra-cardiac  ganglia.  Let  us  bear  in 
mind,  however,  two  considerations,  both  of  which  have  their  value  :  First, 
we  can  only  help  a  fatty  heart  materially  by  stimulating  its  healthy 
fibres.  Now  we  should  not  do  this  to  an  excessive  degree,  because  we 
wish  to  save  those  which  are  degenerated  from  over-action,  or  increased 
pressure  from  within  the  cardiac  cavity,  or  else  we  run  great  risk  of  in- 
creasing cardiac  dilatation,  or  else  producing  rupture,  it  may  be,  which 
would  have  a  fatal  result.  In  the  second  place,  we  are  aware  that  it  is 
not  merely  the  heart  which  is  implicated  in  fatty  cardiac  degeneration, 
the  arteries  are  also  affected  with  morbid  alterations,  usually  of  athero- 
matous nature.  These  changes  may  also  occasion  bad  consequences  if 
undue  arterial  tension  is  produced,  as  rupture  in  some  of  them — particu- 
larly the  cerebral  ones — is  not  uncommon. 

These  objections  may  be  considered  by  some  as  more  theoretical  than 
practical,  and  as  in  no  degree  militating  against  the  employment  of 
cardiac  stimulants  when  their  use  for  other  reasons  seems  advisable.  In 
some  cases  of  distended  cardiac  cavity  through  a  vaso-inhibitory  action 


54  ORGANIC    DISEASE    OF    THE    HEART. 

upon  the  vessels,  the  arteries  are  somewhat  distended.  Digitalis  by  its 
power  over  the  peripheral  circulation  appears  to  restore  these  vessels  to 
their  normal  calibre,  and  hence  its  action  under  these  conditions  should 
be  regarded  as  really  injurious. 

In  cases  where  the  heart  seems  rapidly  to  fail,  as  it  frequently  does 
where  organic  disease  exists  and  an  acute  disease  like  pneumonia  or 
typhoid  fever  is  grafted  upon  it,  digitalis  appears  at  times  to  have  con- 
siderable power  in  lowering  the  temperature  and  thus  benefiting  the 
patient.  Clinically,  the  lowering  of  the  temperature  as  well  as  the 
better  condition  of  the  patient  seem  to  be  accompanied  by  retained  or 
increased  arterial  tension.  When  the  arterial  tension  fails,  not  only  is 
the  condition  of  the  patient,  as  a  rule,  unimproved,  but  the  temperature 
does  not  appreciably  fall.  Perhaps  this  action  of  digitalis  may  serve  to 
explain  some  remarkable  effects  occasionally  obtained  in  the  treatment 
of  pneumonia  and  typhoid  fever,  which  without  this  explanation  would 
seem  to  be  doubtful  or  mysterious.  Of  course,  in  considering  such 
action  we  should  have  in  view  the  effect  of  heart  stimulants,  not  merely 
on  one  factor  of  cardiac  power,  but  upon  alb — many  of  which  are  com- 
bined. 

The  heart,  it  is  true,  is  a  muscle,  and  upon  this  muscle  digitalis, 
strychnine,  convallaria,  caffein,  etc.,  all  act  probably  to  a  certain  degree. 
But  the  heart  muscle  is  controlled  by  the  regular  rhythmic  discharges 
from  its  intrinsic  ganglia,  and  these  are  probably  even  more  effectively 
stimulated  to  action  in  fevers  or  disease  of  microbic  origin  by  the  car- 
diac stimulant  than  the  muscle  itself. 

Belladonna  is  to-day  often  forgotten  as  to  its  beneficial  action  when- 
ever neurosal  difficulty  is  present  in  any  condition  of  heart  depression, 
without  regard  to  the  precise  organic  disease  which  prevails.  Not  many 
years  ago  belladonna  was  much  lauded  not  merely  for  its  valuable  as- 
sistance in  helping  all  cases  of  chronic  heart  disease  where  arterial  ten- 
sion was  low  and  the  quantity  of  urine  daily  voided  quite  insufficient ; 
it  was  also  admitted  to  be  a  very  powerful  agent  for  the  relief  of  the 
effects  of  shock  and  when  the  patient  was  in  a  state  of  collapse  which 
threatened  immediate  death.  Let  us  not  forget,  therefore,  that,  perhaps 
in  many  instances  where  we  fail  to  obtain  relief  from  other  drugs, 
belladonna  may  afford  us  very  valuable  assistance.  Fothergill  insisted 
in  his  work  on  heart  diseases  upon  the  use  to  which  belladonna  might  be 
referred,  and,  with  what  seems  to  be  very  clear  insight,  recommended  it 
highly. 

Not  infrequently  I  have  had  good  reasons  to  believe  that  our  ordinary 
estimate  of  the  value  of  belladonna  is  too  low,  and  am  convinced  that 
if  it  were  more  frequently  prescribed  in  connection  with  strychnine  we 
should  obtain  very  excellent  results  from  it.  In  combination  with  iodide 
of  potassium,  it  certainly  gives  marked  relief  to  many  cases  of  aortic 


ORGANIC    DISEASE    OF    THE     HEART.  55 

disease  in  which  part  at  least  of  the  pain  is  apparently  connected  with  a 
lack  of  synchronous  rhythmic  contractions  between  the  two  sides  of  the 
heart,  connected  with  an  insufficient  or  badly  co-ordinated  nervous  con- 
trol. Possibly,  its  stimulating  effect  upon  the  nervous  centres  controlling 
respiration  may  have  also  great  value  in  the  re-establishment  of  heart 
power  and  more  perfect  rhythmic  action. 

Few  authors  have  insisted  upon  the  value  of  electric  currents  as  a 
means  of  restoring  heart  power.  Reasoning  from  analogy,  I  am  con- 
fident that  we  neglect  too  much  this  means  of  relief.  I  have  seen  such 
notable  good  effects  both  of  faradic  and  galvanic  currents  in  Graves' 
disease;  it  has  been  of  such  evident  and  great  use  to  patients  in  whom 
the  acute  asthenia  grafted  on  the  previous  cardiac  changes  was  of  immi- 
nent gravity,  that  I  feel  as  if  I  have  often  neglected  a  means  that  would 
surely  be  helpful,  if  properly  applied,  when  compensation  is  temporarily 
lessened  or  gravely  impaired.  One  pole  should  be  placed  in  the  region 
of  the  neck,  and  the  other  over  the  cardiac  region,  and  mild  currents 
should  be  daily  applied  for  a  limited  time.  I  trust  that  others  besides 
myself  will  see  the  utility  of  electricity,  and,  it  may  be,  obtain  results 
from  it  in  the  treatment  of  organic  heart  disease  which  have  not  hitherto 
been  secured. 

The  dyspnoea  from  which  patients  affected  with  chronic  cardiac  dis- 
ease suffer,  either  continuously  or  spasmodically,  is  most  distressing ; 
sometimes  it  comes  on  in  a  sudden  manner,  perhaps  in  the  middle  of  the 
night,  with  or  without  a  sufficient  apparent  accidental  cause  to  produce 
it.  Frequently,  however,  these  attacks  follow  imprudences  in  eating  or 
drinking.  Indigestible,  rich  food  taken  late  at  night,  and  after  any  un- 
usual nervous  strain  is  a  frequent  cause  of  similar  attacks  in  the  begin- 
ning of  cardiac  asthenia.  During  the  attack  the  heart  is  unable  to 
expel  its  contents,  and  the  right  heart  particularly  seems  to  be  specially 
involved.  The  patients  are  anxious,  distressed,  panting  for  breath  ;  the 
lips,  face,  and  extremities  are  cyanosed  ;  the  hands  are  cold  and  clammy ; 
there  is  often  free  perspiration  from  the  face  and  neck ;  the  pulse  is 
feeble  and  irregular ;  they  are  often  restless  and  uneasy  and  seek  dif- 
ferent postures  to  relieve  their  breathing  ;  sometimes  they  sit  up  straight ; 
often  they  bend  over  on  a  chair  or  head-rest,  and  fix  their  arms  and 
shoulders  so  as  to  give  them  additional  support,  and  thus  enable  them 
to  use  the  accessory  muscles  of  respiration.  The  heart's  action  is  inter- 
fered with  frequently  by  the  bulging  upward  of  the  diaphragm,  which 
cannot  descend  in  the  abdominal  cavity,  owing  to  gaseous  distention  of 
the  stomach  or  colon.  When  the  stomach  is  full  of  food  and  gas,  nothing 
gives  more  immediate  relief,  at  times,  than  to  have  it  emptied  by  an 
attack  of  vomiting.  On  other  occasions,  the  diffusible  stimulants  given 
internally,  i.  e.,  alcohol,  ammonia,  chloric  ether,  in  frequently  repeated 
doses,  will  be  of  almost  immediate  and  great  use.     If  the  extremities 


56  ORGANIC    DISEASE    OF    THE     HEART. 

are  cold,  hot-water  bags  or  mustard  poultices  applied  to  them  will  help 
restore  the  circulation.  When  the  attack  is  severe  and  the  position  of 
the  patient  imminently  threatening,  hypodermics  of  brandy,  nitro- 
glycerin, strychnine,  or  digitalis  should  be  given  and  repeated  several 
times  until  the  patient  notably  revives.  The  quantities  of  these  drugs 
which  can  be  given  to  these  patients  with  evident  relief  is  often  very 
large.  Of  course,  such  attacks  vary  greatly  as  to  their  gravity,  and  in 
some  instances  life  itself  hangs  upon  a  thread.  I  have  seen  patients 
more  than  once  remain  in  a  semi- collapsed  condition  several  hours  and 
only  revive  thoroughly  after  I  and  others  had  expended  all  our  efforts  in 
their  behalf. 

In  dyspnoea  of  more  chronic  nature  we  find  that  pulmonary  conges- 
tion, bronchitis,  cardiac  dilatation  or  effusion  into  the  pleural  cavities  are 
frequent  causes  of  it.  Any  of  these  thoracic  complications  may  be  ac- 
companied also  by  a  renal  affection  which  renders  the  treatment  more 
difficult  and  the  prognosis  graver — sometimes  the  patient  cannot  lie  down 
at  all  for  many  nights.  This  position,  often  so  painful  to  the  patient,  is 
measurably  relieved  by  a  good  bed-rest,  with  arms  at  the  side  to  prevent 
the  patient's  head  or  body  from  falling  over  or  taking  a  position  which 
greatly  increases  the  difficult  breathing.  Hypodermics  of  morphine 
with  atropine  will  sometimes  quiet  and  subdue  these  attacks  very 
rapidly.  When  these  drugs  fail  to  relieve  in  appropriate  doses,  nitro- 
glycerin is  available  and  most  reliable.  This  is  particularly  true  if  the 
tension  of  the  radial  pulse  is  high  and  there  is  clearly  present  a  state  of 
advanced  arterio  capillary  fibrosis. 

Whenever  there  is  a  moderate  or  large  amount  of  fluid  in  one  of  the 
pleural  cavities,  thoracentesis  repeated  one  or  more  times  gives  great 
relief  to  the  breathing,  and  prolongs  life  many  months  in  some  instances. 
Warm  poultices,  with  the  addition  of  mustard  in  moderate  proportion  to 
the  chest  walls,  is  a  very  excellent  means  to  give  relief  to  distressed 
breathing.  Repeated  applications  of  dry  cups  to  the  chest  or  over  the 
renal  region  are  of  great  value. 

As  soon  as  the  acute  dyspnoea  is  relieved  a  free  purgative  dose  with 
calomel  and  compound  jalap  powder  will  carry  off  considerable  fluid 
from  the  economy,  and  thus  afford  sensible  relief.  Hoffman's  anodyne 
in  full  doses  will  often  quiet  extreme  restlessness  and  promote  sleep,  be- 
sides being  of  great  service  in  lessening  dyspnoea  of  functional  character 
and  nervous  origin,  although  connected  with  organic  heart  disease.  If 
there  is  much  venous  engorgement  we  can  obtain  more  relief  by  blood- 
letting than  in  any  other  way.  Leeches,  wet  cups,  venesection,  may  all 
be  used  in  certain  cases  with  great  advantage  to  the  patient. 

I  have  also  known  oxygen  inhalation  to  be  successfully  employed. 
Again,  even  when  there  is  much  bronchial  engorgement,  oxygen  will 
fail  to  produce  any  amelioration  in  the  patient's  condition.     We  are, 


ORGANIC    DISEASE     OF    THE     HEART.  67 

indeed,  compelled  to  abandon  its  use  at  times  on  account  of  increased 
distress  which  it  evidently  occasions  in  the  breathing.  Inhalations  of 
nitrite  of  amyl,  the  internal  use  of  the  bromides  and  chloral  are  resorted 
to  by  me  with  evident  great  resulting  benefit  in  some  instances.  In  the 
use  of  chloral  one  must  be  guarded  whenever  there  is  danger  of  heart- 
failure  from  organic  cardiac  disease,  as  the  heart  may  suddenly  be 
arrested  in  diastole.  Cardiac  dyspnoea  is  frequently  aggravated  by  an 
underlying  gouty  condition,  by  hysteria,  or  emotional  excitement,  and 
may  be  greatly  relieved  by  appropriate  medication  addressed  to  these 
diverse  causative  conditions. 

The  condition  of  the  stomach  and  liver  is  also  very  important,  and  a 
vomitive  or  purgative  given  at  the  proper  time  is  able  to  afford  much 
relief,  when  otherwise  the  patient's  distress  would  continue.  It  is  wise 
in  many  such  cases  to  be  cautious  is  rendering  too  grave  a  prognosis,  as 
the  occasion  does  not 'always  warrant  it,  and  with  judicious  treatment 
the  patient  may  rapidly  improve. 


ETIOLOGY  AND  TREATMENT  OF  CERTAIN  KINDS 

OF  COUGH.1 


Cough  is  one  of  those  symptoms  we  are  called  upon  constantly  to 
treat.  At  times  the  diagnosis  of  its  cause  is  relatively  easy,  and  our 
treatment  satisfactory.  It  may  last,  it  is  true,  for  some  days  despite  our 
efforts  to  relieve,  and  during  this  time  cause  moderate  annoyance,  or 
even  considerable  distress.  Still,  after  a  fair  trial  of  remedies  judiciously 
employed,  a  measure  of  benefit  is  obtained,  and  both  patient  and  physi- 
cian are  hopeful  as  to  a  speedy  cure,  and  both  are  tolerably  satisfied 
with  the  amount  of  success  accomplished  in  a  given  period.  Again, 
there  are  cases  in  which  we  know  from  the  first  that  whatever  treatment 
may  be  followed  the  obstinate  cough,  in  the  nature  of  things,  must  per- 
sist, and  arrest,  except  from  increasing  doses  of  anodynes,  can  rarely  be 
effected.  Such  cases  we  are  familiar  with  in  certain  forms  of  pulmonary 
and  laryngeal  phthisis. 

There  are  other  kinds  of  cough  which  are  also  met  with  quite  fre- 
quently ;  yet  their  diagnosis  is  made  with  difficulty,  and  their  treatment 
despite  repeated  changes,  fails  to  accomplish  much  in  the  way  of  abate- 
ment and  cure.  This  is  true  not  only  of  the  patients  who  go  first  to  the 
family  physician  in  search  of  help,  but  also  of  those  who  in  the  begin- 
ning of  their  trouble  gravitate  toward  some  prominent  specialist. 

In  the  class  of  cases  where  the  general  practitioner  is  usually  at  fault 
I  would  place  the  cough  which  is  under  dependence  of  an  engorged 
lingual  tonsil.  On  at  least  two  occasions  I  have  treated  wives  of  promi- 
nent medical  practitioners  who  were  sufferers  from  annoying  symptoms 
of  this  origin,  although  previous  to  my  seeing  and  treating  them  the 
nature  of  the  trouble  had  not  been  recognized.  In  these  cases  there  was 
no  chest  affection  and  no  apparent  throat  trouble  sufficient  to  cause  the 
distressing  cough,  or  other  symptoms.  There  was  no  evident  local 
disease  elsewhere  in  one  case  ;  in  the  other  there  were  joint  symptoms  of 
rheumatic  gout.  In  one  case  the  cough  had  resisted  many  usual  reme- 
dies given  internally,  and  the  repeated  employment  of  sprays  and 
inhalation  of  balsamic  vapors. 

The  cough  in  these  cases  is  frequent,  dry,  paroxysmal.  Anodynes, 
even  in  moderately  large  doses,  fails  to  afford  relief.  At  times  the  cough 
is  occasioned  by  the  sensation  of  a  foreign  body  lodged  at  the  base  of 

1  Read  before  the  Climatological  Association,  June  14,  1895. 


ETIOLOGY     AND    TREATMENT    OF    COUGH.  59 

the  tongue,  like  a  bristle,  a  bread  crumb,  or  a  bit  of  meat,  but  it   is 
impossible  to  dislodge  anything  or  get  rid  of  the  annoying  sensation. 

Accompanying  the  cough  there  may  be  a  continuous  desire  to  swallow 
constantly,  and  the  effort  of  deglutition  may  be  performed  with  some 
difficulty.  Indeed,  I  have  had  one  case  under  my  care  in  which  the 
difficulty  of  swallowing  was  so  great  as  to  excite  much  apprehension  lest 
choking  should  occur,  and  the  young  woman  soon  lost  flesh  and  strength 
to  a  marked  degree,  through  dread  of  taking  her  meals.  With  the  diffi- 
culty of  swallowing  there  may  be  a  feeling  of  a  constricting  hand  around 
the  throat,  which  occasionally  seems  as  if  it  would  throttle  the  patient. 
This  sensation  is  greatly  increased  when  the  patient  lies  down  at  night, 
and,  of  course,  increases  his  terror. 

But  these  are  very  exaggerated  cases,  and  frequently  nothing  betrays 
the  evidence  of  local  irritation  of  the  larynx  from  lymphoid  hypertrophy 
at  the  base  of  the  tongue,  except  an  almost  continuous  cough.  I  have 
known  such  cases  to  be  regarded  for  some  time  as  phthisical,  and  again 
as  hysterical. 

When  the  obstinate  cough  is  thought  to  be  evidence  of  incipient 
phthisis,  change  of  air,  absence  from  business  or  household  cares,  cod- 
liver  oil,  and  creosote  begins  to  loom  up  as  the  only  remaining  means  of 
helpfulness.  If  the  patient  be  supposed  to  suffer  from  hysteria — and 
how  often  is  the  so-called  "  globus  hystericus  "  made  to  account  for  what 
is  caused  by  pressure  from  an  offending  mass — little  or  no  treatment  is 
insisted  upon.  The  patient  is  often  spoken  of  as  an  imaginary  sufferer, 
for  whom  a  cold  douche,  valerian  pills,  and  some  moral  education  sum 
up  about  everything  which  can  be  done.1 

When  these  cases  are  examined  with  the  laryngoscope,  and  it  is  only 
with  the  laryngoscope  that  they  can  surely  be  made  out,  we  note  the 
following  conditions:  The  epiglottidean  fossa,  i.  e.,  the  fossa  between 
the  epiglottis  and  the  base  of  the  tongue,  is  more  or  less  completely  filled 
up  and  distended  by  a  slightly  irregular  but  rounded  mass  of  lymphoid 
tissue.  This  mass  is  sometimes  deep  red,  sometimes  pink,  and  again  pale 
in  color.  It  is  often  covered  with  irregular  cauliflower  excrescences  not 
larger  than  a  very  small  pea.  Again,  it  is  relatively  smooth  and 
glistening  like  certain  forms  of  enlarged  faucial  tonsils  in  children.  The 
mass  may  simply  fill  the  fossa,  pressing  against  the  entire  anterior  sur- 
face of  the  epiglottis ;  or  it  may  be  so  much  larger  on  one  side  than  it  is 
on  the  other  that  the  pressure  on  the  epiglottis  is  only  partial,  and  on  the 
opposite  side  to  the  one  where  this  is  evident  the  fossa  is  not  wholly  filled 
up.  Frequently  the  free  border  of  the  epiglottis  is,  to  a  more  or  less 
considerable  extent,  caught  in  or  covered  by  the  overtopping  tonsillar 

1 .1  am  more  inclined  to  the  belief  than  ever  that  the  nervous  cough  of  adolescents  described 
graphically  by  the  late  Sir  Andrew  Clarke  was  simply  a  cough  caused  by  an  enlarged  lingual 
tonsil. 


60  ETIOLOGY    AND    TREATMENT    OF    COUGH. 

mass ;  and  it  would  seem  to  be  particularly  this  portion  of  the  mass 
which  occasions  the  troublesome  cough.  When  the  patient  phonates 
the  mass  occasionally  separates  from  the  free  margin  of  the  epiglottis ; 
occasionally  it  shows  no  separation  at  all,  but  adheres  under  vocal 
efforts  closely  to  it. 

Frequently  there  are  quite  large  veins  distinctly  defined  on  the  ton- 
sillar mass,  and  not  seldom  these  veins  will  burst  and  allow  more  or  less 
blood  to  come  into  the  mouth  and  be  expectorated,  which  I  have  known 
to  cause  the  liveliest  apprehension  on  the  part  of  the  physician  and  the 
patient.  Fortunately,  the  bleeding  soon  stops,  and  the  patient  is  none 
the  worse  for  it,  except  mentally. 

These  enlargements  of  the  lingual  tonsil  are  uncommon  among  young 
children  ;  they  are  also  infrequent  among  young  men  and  women ;  but 
toward  middle  life,  in  men  and  women,  I  have  had  numerous  cases — 
more  among  women  than  men. 

The  causes  of  the  enlargement  are  certain  menstrual  derangements, 
continued  constipation,  and  an  underlying  rheumatic  or  gouty  state. 
No  doubt,  micro-organisms  may  infect  as  readily,  perhaps  even  more 
easily,  this  tonsillar  mass  than  they  do  those  masses  at  the  faucial  en- 
trance. 

In  rare  cases  syphilis  has  doubtless  localized  itself  in  this  region,  either 
causing  marked  hypersemia  or  a  congestive  condition,  upon  which  a 
mucous  patch  may  readily  develop,  as  it  does  upon  the  faucial  tonsils. 

How  should  we  treat  this  engorged  lingual  tonsil  ?  Internally,  we 
must  give  the  salicylates  in  fairly  large  doses,  and  usually  we  shall 
obtain  from  their  use  very  evident  benefit.  It  is  not  essential  in  giving 
the  salicylates  to  be  able  to  discover  some  other  manifest  rheumatic 
symptoms;  nor,  indeed,  should  we  feel  compelled  to  obtain  a  clearly 
rheumatic  history.  Despite  the  absence  of  either  the  one  or  the  other, 
we  often  get  good  results  from  this  treatment. 

In  prescribing  salicylic  acid  or  the  salicylates,  it  is  very  important  to 
get  salicylic  acid  obtained  from  the  proper  chemical  source.  That 
made  directly  from  the  oil  of  wintergreen  is  the  only  one  which  is  safe 
and  judicious  to  use.  The  other  is  very  apt  to  cause  pain  and  nausea 
or  other  symptoms  of  stomachal  intolerance.  While  I  believe  sprays  of 
some  benefit,  especially  those  of  carbolic  acid  combined  with  the  essential 
oils  and  boric  acid,  still  these  will  not  cure  by  themselves  the  lingual 
hypertrophy.  Local  applications  of  a  stronger  kind  are  necessary. 
Among  these,  I  place  foremost  the  galvano-cautery  and  compound  tinc- 
ture of  iodine. 

Excision  of  the  tonsil  by  a  specially  devised  knife  or  guillotine 
(Chappell's)  has  been  recommended  highly  by  a  few  prominent  throat 
specialists,  but  thus  far  has  not  commanded  general  favor.  The  site  of 
the  disease  makes  it  awkward  for  operation  with  the  guillotine  unless  it 


ETIOLOGY     AND    TREATMENT    OF    COUGH.  61 

be  imperatively  required,  and  the  risk  from  annoying  bleeding,  or  some 
other  accident  following  excision,  is  not,  in  my  judgment,  as  small  as  has 
been  affirmed.  Formerly,  I  treated  these  cases  with  repeated  applica- 
tions of  the  galvano-cautery,  and,  upon  the  whole,  my  results  were  grati- 
fying; still,  owing  to  the  soreness  and  swelling  which  lasted  for  several 
days  subsequent  to  the  use  of  the  cautery,  I  had  reason  occasionally  to 
be  troubled  in  mind. 

I  do  not  remember  to  have  had  an  abscess  from  the  peritonsillar 
structure  after  cauterization,  but  I  know  that  several  times  the  tonsil 
was  so  much  inflamed  that  I  sought  relief  for  my  patient  through  re- 
peated lancing  with  a  curved  knife.1  The  great  objection,  however,  to 
the  use  of  the  cautery  in  this  region  is  the  risk  of  burning  the  epiglottis, 
and  particularly  its  free  border.  Unless  the  patient  is  phlegmatic  and 
obedient,  and  holds  himself  very  steadily,  we  may  inadvertently  pro- 
duce an  ugly  sore  which  will  give  any  amount  of  trouble  before  it  heals. 

Latterly,  by  repeated  applications  of  compound  tincture  of  iodine 
to  the  tonsillar  mass  with  a  curved  brush  or  sponge-holder,  and  by  the 
use  of  the  salicylates  internally,  I  have  been  able  in  a  few  weeks  to 
reduce  these  enlarged  tonsils  so  that  they  ceased  to  occasion  cough  or 
other  symptoms  of  local  distress.  The  applications  of  iodine  may  be 
repeated  daily  with  considerable  advantage,  or  as  frequently  as  can  be 
made  without  causing  marked  local  soreness.  Even  when  the  cough 
disappears,  or  the  obstructed  deglutition  is  no  longer  present,  the  voice 
may  be  more  or  less  hoarse  and  discordant  for  some  time. 

In  using  the  galvano-cautery  it  must  always  be  borne  in  mind  that 
an  unfortunate  burning  of  the  margin  of  the  epiglottis  may  bring  on  a 
cough  even  more  troublesome  than  the  one  we  are  trying  to  cure,  and 
for  this  reason,  after  considerable  experience,  I  am  inclined  to  reserve 
its  use  for  those  cases  in  which  internal  treatment  and  the  local  use  of 
compound  tincture  of  iodine  remain  without  curative  effect. 

Another  form  of  cough  occurs  in  young  children,  and  is  often  ignored, 
or,  if  not  ignored,  the  treatment  is  at  least  ineffectual,  as  it  does  not  reach 
the  cause  of  it.  Frequently  children  cough  repeatedly,  and  at  night 
especially,  on  account  of  one  of  two  conditions  :  either  there  is  a  dropping 
of  thick  mucus,  or  muco-pus,  from  the  nasopharynx  upon  or  into  the 
larynx,  or  there  is  an  irritation  of  the  posterior  turbinated  bodies 
brought  on  by  local  congestion.  The  first  condition  is  made  evident 
frequently  by  the  examination  of  the  pharynx  with  an  ordinary  tongue 
spatula.  So  soon  as  the  tongue  is  moderately  depressed  the  child  has 
an  effort  of  gagging,  and  a  large  mass  of  mucus  is  seen  between  the  free 
border  of  the  palate  and  the  pharyngeal  wall,  squeezed  downward  by 

1 1  have  had  two  cases  under  my  care  in  whom  an  abscess  formed  in  this  tonsil,  and  after 
causing  great  distress,  i.  e..  dyspnoea  and  choking,  burst  spontaneously,  to  the  great  and  imme- 
diate relief  of  the  patients. 


62  ETIOLOGY    AND    TREATMENT    OF    COUGH. 

the  forced  effort  which  just  precedes  its  appearance.  Usually  this  con- 
dition in  children  is  due  to  more  or  less  development  of  the  pharyngeal 
tonsil  or  lymphoid  tissue  at  the  vault  of  the  pharynx.  It  can  be  cured 
by  a  moderate  scraping  with  the  finger-nail  of  the  right  index-finger 
introduced  behind  and  above  the  soft  palate.  If  the  finger  be  properly 
protected  by  a  thick  rubber  nipple  (i.  e.,  such  a  one  as  is  used  to  cover 
the  mouth  of  a  nursing  bottle)  it  will  not  be  wounded  by  the  child's 
teeth.  No  anaesthesia  is  required.  The  pain  from  the  scraping  is  very 
slight,  and  the  operation  lasts  but  a  few  moments.  To  be  thorough,  two 
or  more  scrapings  should  be  made  at  the  time,  or  if  the  child  is  very 
restive  after  the  first  operation  further  interference  may  be  delayed  until 
a  later  and  more  favorable  occasion.  In  some  of  these  cases  there  is 
quite  an  amount  of  bleeding  for  a  few  moments  during  and  immediately 
after  the  operation  ;  but  in  my  experience  it  has  quickly  ceased.  If  it 
were  to  continue  I  would  advise  swabbing  the  post-nasal  space  with  a 
little  of  Mackenzie's  tanno-gallic  powder  (three  parts  of  tannin  and  one 
part  of  gallic  acid).  Indeed,  I  have  made  this  application  on  more 
than  one  occasion  as  a  simple  matter  of  precaution,  and  with  obviously 
a  satisfactory  astringent  effect. 

In  the  event  of  the  hemorrhage  being  at  all  abundant  or  continuing, 
for  any  length  of  time,  the  proper  thing  to  do  would  be  to  place  a  plug  of 
iodoform  or  sterilized  gauze  in  the  post-nasal  space  with  the  finger  or  a 
pair  of  post-nasal  forceps,  allowing  a  string  to  remain  attached,  so  that 
the  tampon  could  be  removed  at  any  moment  it  seemed  advisable  to 
do  so. 

For  a  few  days  subsequent  to  the  scraping  it  is  wise  to  spray  the  nasal 
and  post-nasal  passages  with  a  mild  antiseptic  spray  composed  in  part 
of  carbolic  or  boric  acid. 

Sometimes  there  is  really  no  adenoid  tissue  in  the  post-nasal  space  to 
account  for  the  obstinate  cough,  and  there  is  practically  no  hypersecre- 
tion of  mucus  or  muco-pus  from  this  region. 

The  nasal  passages  may  be  either  tolerably  pervious,  or  they  may  be 
notably  occluded.  Sometimes  the  occlusion  is  but  little  noticed  in  the 
day-time,  but  at  night  it  becomes  greatly  aggravated,  and  especially 
when  the  patient  is  lying  on  his  back,  he  is  restless  aud  uncomfortable, 
throws  himself  about  the  bed,  coughs  frequently,  and  yet  apparently  there 
is  not  sufficient  evidence  in  an  ordinary  inspection  of  the  fauces  and 
pharynx  to  account  for  these  morbid  phenomena. 

At  times  the  cough  is  relieved  very  much  for  some  time  by  a  suitably 
formulated  nasal  spray  or  a  few  applications  of  moderate  severity  to  the 
nasal  mucous  membrane. 

I  have  found  albolene  with  camphor  and  carbolic  acid  one  of  the  best 
combinations  as  a  spray  or  vapor,  and  applications  of  carbolic  acid  and 
glycerin  (from  1  part  to  8  to  equal  parts  of  each  ingredient)  as  the  most 


ETIOLOGY     AND    TREATMENT    OF    COUGH.  63 

useful  local  application  by  means  of  a  nasal  carrier,  I  have  hitherto 
employed  in  these  cases. 

Whenever  the  cough  is  not  altogether  relieved  by  these  means  used  in 
the  manner  referred  to,  I  find  it  is  most  useful  to  paint  over  the  posterior 
end  of  the  turbinated  bodies  (as  much  as  I  am  able;,  and  also  the  vault 
of  the  pharynx,  with  carbolic  acid  and  glycerin  (1  part  carbolic  acid 
to  6  or  8  parts  of  glycerin).  In  this  way  we  are  able  surely  to  relieve 
the  congested  condition  which  is  so  distressing,  and  no  doubt,  by  dimin- 
ishing the  sensitiveness  of  the  peripheral  nerve  filaments  here  distrib- 
uted, to  cure  the  reflex  attacks  of  coughs  which  have  proved  so  dis- 
tressing. 

It  is  most  important,  however,  in  just  such  instances  to  avoid  over 
loading  the  child's  stomach  at  bed-time  with  heavy,  rich,  or,  indeed,  too 
abundant  food.  A  light  supper,  mainly  composed  of  bread  and  milk, 
with  a  little  stewed  fruit,  is  about  all  that  such  a  child  should  be  allowed 
to  take  at  its  evening  meal.  If  the  liver  be  engorged  from  a  too  large 
food  supply,  the  result  is  temporary  blocking  of  the  circulation ;  and 
hence,  in  many  cases,  nasal  obstruction  and  cough.  Am  I  not  borne  out 
in  my  statement  when  many  of  us  acknowledge  that  certain  cases  of  fre- 
quent, obstinate  nasal  hemorrhage  are  only  permanently  arrested  by  a 
rigid  dietary  and  repeated  counter-irritation,  or  depletion  over  the  hepatic 
region. 

Just  in  the  same  way  as  a  hyper- sensitive  area  may  be  discovered  in 
some  portion  of  the  nasal  passages  or  nasopharyngeal  space,  so  I  find 
occasionally  sensitive  areas  in  the  pharynx,  in  the  tonsillar  region,  upon 
the  soft  palate,  in  the  hyoid,  or  epiglottidean  fossa,  which  will  occasion 
cough  as  soon  as  we  touch  the  irritable  point. 

In  what  manner  it  is  best  to  destroy  these  areas  of  cough  is  hard  to 
affirm  absolutely.  Sometimes  I  have  found  one  agent,  sometimes  another, 
relieve  most.  Nor  is  it  always  true  that  astringent  or  caustic  applica- 
tions will  do  better  than  soothing  anodyne  ones,  or  vice  versa. 

All  local  remedies  at  times  remain  futile,  and  cough  persists  and 
annoys  until  an  entire  change  of  air  and  scene  are  obtained. 

Of  the  internal  remedies  from  which  I  have  derived  most  benefit,  I 
would  mention  codeia  and  terpin  hydrate.  Codeia  does  not  simply  re- 
lieve hyper-sensitiveness  for  a  while,  it  is  also  directly  curative  ;  more- 
over, it  does  not  constipate  the  bowels  much,  as  a  rule,  or  upset  the 
stomach,  as  morphine  or  opium  almost  invariably  do.  Terpin  hydrate 
may  have,  in  addition  to  its  well-known  modifying  action  on  diseased 
mucous  membrane,  a  mild  antimicrobic  power  that  perhaps  is  useful. 
It  always  remains  true  that  codeia  in  doses  of  gr.  y1^,  more  or  less  fre- 
quently repeated,  and  terpin  hydrate  in  tablet  form  of  1  or  2  grs.  each, 
every  two  or  three  hours,  given  internally,  have  been  of  great  service 
in  my  hands. 


64  ETIOLOGY    AND    TREATMENT    OF    COUGH. 

I  have  not  been  able  to  determine  invariably  the  cause  of  these  sensi- 
tive areas.  I  meet  them  occasionally  in  young  girls  of  marked  nervous 
temperament,  who  are  also  ansemic  and  somewhat  exhausted  from  too 
much  work,  study,  or  pleasure.  I  also  encounter  them  when  the  general 
health  is  excellent,  and  it  is  impossible  to  get  at  a  satisfactory  cause. 

Every  practitioner  is  familiar,  at  least  theoretically,  with  the  fact  that 
paroxysmal  cough  may  be  occasioned  by  irritation  in  the  auditory  canal. 
Most  physicians  have  known  the  mere  introduction  of  a  probe  or  ear 
speculum  to  be  followed  by  an  outbreak  of  cough,  which  only  terminated 
when  the  offending  instrument  was  withdrawn.  Sometimes  the  condi- 
tion of  the  ear  is  such  that  we  can  readily  account  for  cough  produced 
by  examination,  or,  indeed,  for  the  cough  which  previous  to  the  aural 
examination  had  remained  a  great  mystery.  Frequently,  an  impacted 
mass  of  cerumen  explains  the  cough,  apparently,  and  after  complete  re- 
moval of  this  substance  the  cough  will  speedily  disappear. 

There  are  numerous  occasions,  however,  in  which  there  is  no 
impacted  cerumen  and  no  symptoms  of  aural  disease  prior  to  direct 
investigation  by  the  physician.  Then  it  is,  and  only  then,  that  we  first 
discover  that  there  is  some  impairment  of  the  auditory  function.  But 
what  interests  us  particularly  to  state  is  that,  one  or  more  points  of  the 
auditory  canal  are  especially  sensitive,  and  appear  to  have  some  connec- 
tion with  the  appearance  or  continuance  of  the  cough.  In  any  event, 
when  the  sensitiveness  of  the  aural  canal  is  diminished  by  suitable  local 
applications,  the  cough  tends  to  diminish  or  disappear.  The  point  most 
frequently  sensitive  is  that  on  the  posterior  inferior  wall  of  the  canal 
very  close  to  the  membrane  of  the  tympanum.  Accompanying  this 
sensitiveness,  there  is  pronounced  redness  of  the  surface  of  the  canal, 
with  slight  furfuraceous  exfoliation  of  the  cutaneous  layer,  which  shows 
distinctly  inflammatory  action. 

Repeated  applications  of  alcohol,  or  a  mild  solution  of  bichloride  of 
mercury  (1-1000),  or  of  nitrate  of  silver  (1-100),  will  cure  this  condi- 
tion after  a  time,  as  well  as  ameliorate,  if  not  cure,  the  paroxysmal  cough 
from  which  the  patient  suffers.  In  many  such  cases,  however,  there  is  a 
marked  lithsemic  condition,  and  we  will  help  not  only  the  condition  of 
the  auditory  canal,  but  also  the  secondary  or  concomitant  congestion  of 
the  pharynx  and  larynx  by  frequent  doses  internally  of  lithia  and 
bicarbonate  of  potash,  together  with  some  heart  tonic  like  caffeine,  which 
is  also  useful  in  promoting  urinary  excretion. 

Of  course,  in  many  cases  like  those  of  which  I  have  been  writing,  the 
aural  inflammation  and  a  catarrhal  condition  of  the  upper  air-passages, 
with  marked  increase  of  secretion,  may  exist  together,  and  it  is  almost 
impossible  to  say  that  the  ear  is  in  any  sense  the  source  of  the  cough,  as 
this  symptom  may  be  wholly  caused  by  an  independent  laryngitis  or 
tracheitis  which  is  present. 


ETIOLOGY    AND    TREATMENT    OF    COUGH.  66 

In  speaking  on  this  subject  of  aural  reflexes,  it  may  be  remarked  with 
a  feeling  akin  to  surprise  how  no  attention  is  paid  to  it  in  late  editions 
of  works  on  aural  disease,  like  Politzer  and  Buck  ;  Dench,  it  is  true, 
speaks  about  the  reflexes  originating  in  the  auditory  canal,  in  his 
chapter  on  impacted  cerumen,  but,  so  far  as  I  could  discover,  nowhere 
else;1  and  yet  it  is  a  matter  of  common  knowledge,  almost,  that  "ear 
cough  "  exists.  Despite  this  statement,  I  trust  in  a  practical  way  my 
reference  to  it  in  this  paper  may  still  be  found  suggestive  and  useful. 

One  of  the  most  interesting  facts  connected  with  cough — originating 
evidently  in  the  upper  air-passages — is  how  little  we  can  judge,  at  times 
of  the  source  or  nature  of  the  cough  from  visible  appearances ;  some  of 
the  worst-looking  throats  give,  at  times,  literally  no  symptoms,  and,  for 
one,  I  am  disposed  to  regard  these  throats  as  usually,  if  not  always, 
normal.  Symptoms  are  evidences  of  disordered  function,  and  are  appre- 
ciated by  our  organs  of  sense  and  the  reports  given  us  by  the  patients 
themselves.  If,  therefore,  none  can  be  found  and  none  are  accused,  is 
not  this  sufficient  proof  that  the  organ  itself  is  probably  healthy  ?  Again, 
we  shall  have  all  the  appearances  of  a  healthy  mucous  membrane,  and 
yet,  strange  to  say,  the  patient  is  always  complaining  of  abnormal  or 
unpleasant  sensations,  or  functional  disability  in  the  vocal  muscles. 
These  statements  are  not  always  .exaggerated  ;  they  are  probably  often 
true,  and,  if  rightly  interpreted,  lead  us  to  a  correct  explanation  and 
treatment  of  them. 

Many  years  ago  I  reported  a  case  of  chronic  laryngitis,  which  served 
to  illustrate  how  the  mucous  membrane  of  the  vocal  cords  may  be  in  an 
objectively  morbid  condition,  though  their  physiological  functions  be  re- 
stored (The  American  Journal  of  the  Medical  Sciences,  October, 
1875).  In  an  analogous  way,  I  might  also  show  at  present  how  certain 
patients  affected  with  redness  and  swelling  of  the  larynx  cough  a  great 
deal,  and  others  do  not.  Of  course,  we  can  readily  affirm  that  in  the 
one  case  there  is  some  point  of  continuous  irritation  elsewhere  which 
causes  constant  cough,  and  in  the  other  there  is  not.  Such  explanation 
is,  however,  nothing  more  at  times  than  a  surmise,  and  we  are  thrown 
back  upon  our  inadequate  knowledge  at  present  to  give  a  complete  and 
satisfactory  solution  of  such  examples. 

In  just  such  instances  I  have  found  the  best  curative  effects  in  a 
change  of  air  and  scene.  I  am  not  confident  that  it  is  of  essential  im- 
portance that  the  change  shall  be  from  the  city  to  the  country,  or  to  a 
seaside  resort.  Sometimes  the  change  from  one  city  to  another  will  rid 
the  patient  of  an  obstinate  cough  which  may  have  lasted  for  weeks  and 
resisted  much  and  various  medication.      Frequently,  however,  I  send 

1 1  do  not  wish  to  mislead,  so  that  I  would  add  that  Dench  has  a  most  excellent  chapter  on 
"  Aural  Reflexes,"  but  all  due  to  disease  elsewhere,  and  not  in  the  canal  itself. 


66  ETIOLOGY    AND    TREATMENT    OF    COUGH. 

these  patients  inland  to  breathe  the  air  of  pine  forests,  and  where  the 
soil  is  porous  and  well  drained,  and  thus  obtain  most  satisfactory- 
results.  I  know,  however,  of  one  seashore  resort,  i.  e.,  Atlantic  City, 
N.  J.,  which  even  during  the  winter  months  has  been  most  beneficial 
to  cases  of  "  cough "  which  had  resisted  other  remedial  agencies. 
The  special  value  of  this  shore  climate  appears  to  consist,  singular  to 
relate,  in  its  relative  dryness  as  compared  with  many  other  places  on 
the  ocean. 

In  the  early  spring  there  is  nothing  which  will  remove  a  harassing 
cough  of  this  kind  sooner  than  a  few  days'  trout-fishing  with  rod  and 
reel.  In  the  summer,  when  I  am  able,  I  like  to  send  those  who  cough 
obstinately  to  some  good  sulphur-spring,  as  I  am  satisfied  that  not  only 
the  air  in  the  vicinity  of  sulphur-springs,  but  also  the  sulphur-baths  and 
inhalations  are  very  useful  in  building  up  impaired  nervous  constitutions 
in  which  such  coughs  often  predominate. 

Alongside  of  these  individuals  there  are  others  who  are  apparently  in 
good  health  and  yet  are  constantly  hawking,  coughing,  and  expectorat- 
ing. Usually  these  patients  are  lithsemic  to  an  intense  degree,  and  after 
a  while  the  lithsemic  state  is  complicated  by  the  presence  of  an  elongated 
palate  and  a  thickened,  congested  pharynx  and  larynx.  Lithsemia,  if 
continuously  neglected,  may  become,  or  find  expression  in,  an  evident 
rheumatic  or  gouty  state.  Under  these  circumstances  it  is  not  uncommon 
to  find  the  mucous  membrane  of  the  upper  air-passages  much  infiltrated. 
Frequently  this  extends  far  down  the  trachea,  and  tenacious  mucus  is 
pretty  constantly  present  and  is  expelled  with  difficulty. 

Such  a  condition  and  the  cough  dependent  upon  it  is  helped  more  by 
salicylate  of  soda  or  the  salts  of  lithia  than  by  local  applications  or 
anodyne  cough  mixtures.  I  have  already  on  a  former  occasion  pointed 
out  the  marked  influence  of  malaria  in  producing  congestive  conditions 
of  the  respiratory  passages  which  occasion  rebellious  cough.  This  mani- 
festation is  often  with  difficulty  traced  to  its  cause,  and  medication  alone 
seems  to  establish  the  diagnosis. 

In  a  few  such  cases  it  has  seemed  evident  to  me  that  quinine  and 
arsenic  would  not  benefit,  when  bark,  in  tincture  or  fluid  extract,  fre- 
quently repeated  and  in  sufficient  doses,  was  certainly  curative.1 

The  obstinate  cough  due  to  a  dilated  heart,  or  one  affected  at  the 
orifices  with  organic  changes,  is  very  frequent,  and  should  be  constantly 
kept  in  mind.  Not  seldom,  when  I  have  not  known  what  else  to  do,  I 
have  freely  stimulated  a  somewhat  weak  cardiac  action  and  thus  stopped 
a  bad  cough  in  a  few  days.     Previously  the  patient  had  taken  numerous 

1  In  this  connection  I  would  remark  that  certain  cases  of  pneumonia  are  evidently  malarial 
in  origin.  In  one  case  I  can  now  distinctly  remember,  in  which  Dr.  Loomis  was  the  con- 
sultant, the  typical  signs  of  pneumonia  disappeared  within  twenty-four  hours  under  anti- 
malarial treatment. 


ETIOLOGY    AND    TREATMENT    OF    COUGH.  67 

medicines,  with  little  or  no  benefit.  It  is  not  always  possible  to  make 
out  any  cardiac  murmur,  but  it  is  indicated  in  these  cases  occasionally 
to  give  heart  tonics,  even  more  than  if  a  loud  murmur  were  present. 
The  result  is  indeed  very  surprising  at  times,  and  the  cough  disappears 
very  rapidly.1 

Instead  of  the  rheumatic  dyscrasia  affecting  the  joints  it  may  lodge 
itself  in  serous  membranes  like  the  pleura  or  peritoneum.  In  attacking 
the  pleura  it  produces  only  slight  pain  at  times,  and  for  this  reason, 
doubtless,  no  recognition  of  the  cause  of  cough  is  made  out.  I  have  also 
known  a  case  where  the  ear  could  detect  little  or  nothing  by  ausculta- 
tion, and  yet  I  felt  sure,  through  repeated  observations  and  treatment, 
that  pleuritis  was  the  cause  of  the  cough.  One  or  two  small  fly-blisters 
locally  applied  in  the  beginning  aborted  the  attack,  and  very  soon  the 
patient  was  well.  Sometimes  the  merely  mechanical  action  of  an  en- 
larged spleen  or  liver  pressing  on  the  diaphragm  will  occasion  cough. 
By  slightly  forcing  these  organs  downward  and  inward,  a  paroxysm  of 
cough  may  also  be  occasionally  produced.  In  these  instances,  a  specially 
sensitive  area  is  found  over  the  lower  margin  of  the  liver  or  spleen. 

In  many  instances  of  cough  of  various  kinds  I  have  obtained  very 
great  temporary  relief  from  dry  vapor  inhalations  of  different  volatile 
fluids.  The  best  combination  of  this  kind  which  I  have  hitherto  dis- 
covered consists  of  equal  parts  of  camphor,  menthol,  and  eucalyptus. 
This  I  use  as  an  inhalation  both  for  throat  and  nose.  The  addition  of 
spirits  of  chloroform,  as  we  all  know,  to  these  inhalations  will  be  found 
often  very  useful. 

In  all  cases  of  cough  arising  from  severe  bronchial  inflammation,  or 
in  those  from  broncho-pneumonia,  I  am  now  strongly  in  favor  of  using 
inhalations  of  beechwood  creosote  mixed  with  steam.  They  are  valuable 
in  the  cure  of  these  diseases  and  relieve  cough  very  much. 

No  doubt  the  antimicrobic  action  of  the  creosote  is  serviceable.  In 
several  instances  of  grip  that  I  have  treated  I  am  thoroughly  convinced 
that  the  cough  of  this  disease  was  diminished  more  with  inhalations  of 
creosote  than  in  any  other  manner.  As  a  preventive  means  of  treat- 
ment of  cough  I  have  no  doubt  in  my  mind  that  a  resort  like  Hot 
Springs,  Virginia,  where  we  now  are,  is  most  useful.  By  making  the 
skin  and  kidneys  more  active,  and  stimulating  the  function  of  the  liver, 
these  baths  and  the  massage  treatment  which  follows  must  render  great 
service.  In  the  bracing  mountain  air  and  the  dietary  control  exercised 
by  the  resident  physician  we  have  additional  useful  influences. 

1 1  meet  occasionally  with  cases  of  evidently  slight  cardiac  dilatation,  characterized  by  a  sys- 
tolic bruit,  which  appear  and  disappear  in  a  brief  period.  Fatigue  causes  them ;  rest  and 
cardiac  tonics  cure  them,  at  least  for  a  time. 


PROGNOSIS  IN  HEART  DISEASE. 


In  many  special  treatises  on  diseases  of  the  heart,  especially  those 
which  have  been  published  in  later  years,  the  prognosis  of  heart  disease 
is  pronounced  less  grave  than  it  was  formerly.  Be  it  understood,  how- 
ever, that  distinctions  are  made,  and  very  properly,  between  the  prog- 
nosis of  valvular  defects,  with  and  without  complicating  dilatation,  or 
structural  changes  of  heart  muscle.  What  is  true  of  special  treatises 
is  equally  true  of  certain  well-considered  articles  in  current  periodicals 
on  prognosis  of  heart  disease.  This  is  well,  since  formerly,  as  we  know, 
both  for  the  public  and  many  in  our  profession,  heart  disease  once 
proclaimed  was  also  immediately  stated  to  be  incurable.  In  a  similar 
manner,  if  a  death  occurred  suddenly  or  apparently  in  an  unexplained 
manner,  heart  disease  was  frequently  made  to  account  for  it.  Some- 
times there  was  really  no  reason  for  this  belief,  or,  again,  the  evidence 
of  previous  heart  disease  was  quite  insufficient ;  or,  still  further,  while 
it  was  known,  or  understood,  that  the  dead  person  had  during  life  some 
"  so-called  "  heart  affection,  it  was  not  accurately  determined  what  the 
nature  of  the  cardiac  trouble  was.  All  this  was  a  great  pity,  indeed, 
very  damaging  to  the  profession,  because  it  was  felt  that  our  knowl- 
edge was  very  imperfect.  At  one  time,  for  example,  a  diagnosis  of 
heart  disease  was  made,  a  serious  prognosis  confidently  stated,  and  yet 
the  patient  lived  on  and  enjoyed  very  good  health  for  many  long  years, 
and  was  able  without  inconvenience  to  take  part  in  all  ordinary  affairs 
of  life.  In  other  instances,  it  is  true,  a  similar  diagnosis  and  prog- 
nosis were  made,  and  death,  unfortunately,  did  occur  very  soon,  some- 
times suddenly  or  rapidly,  sometimes  after  a  period  of  several  months 
or  years  of  prolonged  physical  disability  and  suffering.  Evidently  error, 
ignorance,  lack  of  fine  discrimination  and  judgment,  both  in  diagnosis 
and  prognosis,  were  responsible  for  this  situation,  and  it  is  high  time 
that  we  should  with  increasing  knowledge  try  to  bring  definiteness  into 
many  important  questions.  It  is  difficult  to  do  so  wholly,  as  is  shown 
by  the  writings  of  a  few,  who  even  to-day  are  among  our  most  advanced 
and  prominent  medical  writers.  But  it  is  desirable  to  map  out  as  well 
as  possible  some  important  relations  or  essential  facts. 

One  thing  is  true,  and  may  be  properly  admitted  from  the  start,  that 
heart  disease  in  general  is  quite  as  amenable  to  treatment  as  diseases  of 


PROGNOSIS    IN     HEART    DISEASE.  b'9 

other  important  organs  of  the  body  (Semple).  Of  course,  if  at  any 
time  the  heart  stops  beating  for  any  appreciable  time,  death  inevitably 
follows ;  but  this  statement  in  no  way  controverts  the  previous  one  any 
more  than  to  say  that  if  the  lungs  do  not  expand  death  must  surely 
follow.  Prognosis,  as  we  know,  means  foreknowledge  of  what  will 
occur.  It  therefore  takes  in  and  declares  the  probable  course  and 
sequence  of  a  particular  condition  of  organ.  Considered  in  this  aspect 
it  is  indeed  a  part  of  diagnosis,  and  a  very  essential,  not  to  say  the  most 
important  part  (Broadbent). 

In  former  times,  before  Laennec  introduced  his  wonderful  discovery 
of  mediate  auscultation,  knowledge  of  heart  disease  was  very  inaccurate, 
and  many  judgments  were  very  much  like  guesswork.  Even  in  Laen- 
nec's  day,  while  the  abnormal  cardiac  murmurs  were  recognized,  their 
accurate  pathological  significance  was  imperfectly  determined.  Now, 
when  diagnosis  of  heart  disease  is  made,  the  well-informed  physician 
should  be  able  to  tell  in  advance  in  many  instances  what  will  surely 
occur.  This  results  from  the  close  relationship  which  has  been  established 
between  clinical  observation  during  life  and  the  results  of  post-mortem 
examinations.  As  a  consequence,  we  can  frequently  warn  relatives  or 
friends  of  the  patient  when  his  condition  is  such  as  to  inspire  real  solici- 
tude. We  can  also  judge  when  the  heart's  action  is  no  longer  suffi- 
cient fully  to  answer  to  the  task  required  of  it,  and  secondary  symptoms 
of  its  inadequacy  have  become  manifest,  that  a  fatal  result  will  not  long 
be  delayed.  Again,  we  know  that  in  advanced  aortic  disease,  for  ex- 
ample, sudden  death  is  always  more  or  less  imminent,  and  the  fact  should 
not  be  ignored  when  important  family  and  personal  affairs  are  in  a  way 
to  be  determined,  and,  perhaps,  acted  upon  in  view  of  this  knowledge. 
On  the  other  hand,  we  can  feel  confident  at  times  that  the  importance 
of  pathological  bruits  is  much  exaggerated,  and  this  w:rong  estimate  is 
merely  due  to  the  fact  that  their  consequences  are  misstated  or  misin- 
terpreted. Hence,  we  are  fortunately  prevented  from  causing  undue 
anxiety  or  terror  when  there  is  really  no  reason  to  be  specially  appre- 
hensive at  the  time  the  murmur  is  first  recognized,  or,  later,  provided 
an  intelligent  supervision  and  judicious  care  of  the  person  affected  be 
exercised.  What  is  also  true,  however,  and  what  should  never  be  ignored, 
but  make  us  additionally  careful  and  watchful  always,  is  the  fact  that 
many  serious  affections  of  the  heart,  where  there  is  limited  or  diffuse 
structural  degeneration,  are  not  infrequently  present,  and  yet  they  are 
never  detected  during  life,  and  it  is  only  at  the  necropsy  that  the  fatal 
result  is  clearly  explained  and  accounted  for.  Whenever,  in  ausculta- 
tion of  the  heart,  an  abnormal  murmur  is  discovered,  it  is  a  matter 
requiring  careful  consideration  as  to  whether  the  patient  should  be 
informed  of  the  fact,  particularly  if  prior  to  this  sometimes  accidental 
discovery  by  the  attending  physician   the  patient   never  experienced 


70  PROGNOSIS    IN    HEART     DISEASE. 

any  unpleasant  symptoms  from  its  presence.  It  is  clear,  then,  that 
whilst  it  may  be,  and  often  is,  an  obvious  duty  to  inform  the  nearest 
kin  of  the  evidences  of  heart  disease  which  exist  in  an  individual  where 
the  probable  consequences  are  serious  or  fatal,  it  is  unwise  to  accentuate 
a  situation  and  convey  wrong  impressions  about  a  thing  of  little  moment. 
Of  course,  it  is  very  wrong,  where  the  risks  of  a  heart  affection  are 
grave  or  imminent,  to  withhold  this  knowledge  from  relatives  or  friends, 
and  later,  when  the  worst  has  occurred,  then  only  to  announce  the  truth 
which  was  very  truly  determined  by  us  some  time  previously. 

It  may  be  now  fully  understood  that  to  make  an  accurate  prognosis 
of  heart  disease  requires  the  highest  wisdom,  widest  experience,  and 
keenest  insight  of  disease  on  the  part  of  the  clinician  (Broadbent).  It 
is  this  power  of  prognosis  which  wins  confidence  of  patients  more,  per- 
haps, than  any  other  quality ;  and  whenever  the  future  course  of  dis- 
ease corresponds  with  the  statements  made  by  the  practitioner  it  tends 
in  a  marked  degree  to  increase  their  fealty  toward  him,  and  strengthens 
their  recognition  that  in  him  they  have  found  their  most  trusty  adviser. 
In  a  past  generation,  among  those  who  have  most  advanced  our  knowl- 
edge and  discrimination  of  heart  disease  we  should  mention  Bouillaud, 
Stokes,  Hope,  and  Williams.  To-day  these  men  have  been  ably  followed 
by  Sansom,  Balfour,  and  Broadbent.  It  is  to  the  latter  particularly 
that  we  are  largely  indebted,  I  believe,  for  much  knowledge  we  now 
have  to  base  our  prognosis  on  probabilities  which  shall  render  our  fore- 
sight of  the  course  and  consequences  of  heart  disease  more  intelligent 
and  satisfactory  than  it  has  ever  been  prior  to  the  present  period.  To 
those  who  are  unfamiliar  with  his  papers,  I  would  direct  careful  atten- 
tion to  his  lectures  on  "  Prognosis  in  Valvular  Disease  of  the  Heart," 
delivered  before  the  Harveian  Society  in  1884,  and  to  the  Lumleian 
Lecture  at  the  Royal  College  of  Physicians  on  "  Prognosis  in  Struc- 
tural Disease  of  the  Heart,"  delivered  in  1891.  As  he  has  pointed  out, 
whatever  makes  one's  prognosis  of  heart  disease  more  accurate  also 
improves  our  treatment. 

In  the  first  studies  of  Broadbent  treatment  was  not,  however,  touched 
upon,  and  it  is  only  at  a  later  period  in  his  able  work  on  heart  diseases, 
published  in  London  in  1897,  that  this  subject  is  given  the  attention 
it  demands.  This  is  true  in  its  widest  acceptation,  for  the  reason  that 
we  know  from  frequent  experience  that  many  states  of  the  heart  are 
favorably  influenced  by  treatment  only  when  we  consider  fully  all  the 
bearing  which  disorders  alsewhere  in  the  economy  may  have  upon  them. 
We  shall  first  consider  the  prognosis  in  valvular  disease  of  the  heart, 
as  these  are  the  affections  we  meet  with  most  frequently,  and,  moreover, 
are  those  about  which  we  have  most  accurate  information.  In  these 
affections  it  is  important  to  know  the  valve  or  orifice  affected,  as  well 
as  to  know  the  stage  of  the  disease.     Thus,  for  example,  if  it  be  the 


PROGNOSIS    IN     HEART*    DISEASE.  71 

aortic  orifice  which  is  involved,  we  know  the  danger  of  sudden  death 
from  this  form  of  disease  is  only  too  real.  Indeed,  it  has  heen  stated 
by  more  than  one  eminent  authority  that  it  is  the  sole  form  of  valvular 
disease  in  which  a  sudden  fatal  result  is  to  be  dreaded.  To  this  I  can 
scarcely  subscribe,  if  I  be  permitted  to  recur  to  my  personal  experience. 

Already  several  times  T  have  had  under  my  care  in  hospital  wards 
patients  who  were  under  treatment  for  manifestations  of  cardiac  inade- 
quacy, functionally  speaking,  and  who  died  suddenly  with  slight  pre- 
monition of  what  would  occur.  It  is  true  that  in  these  instances  the 
patients  were  being  treated  for  symptoms  more  or  less  disturbing,  and 
while  we  did  not  anticipate  a  fatal  termination  so  suddenly,  yet  we  cer- 
tainly regarded  the  patients  as  sufferers.  In  aortic  regurgitation  it  is 
different,  since,  in  many  instances,  the  patient  seems  very  well  indeed, 
able  and  willing  to  indulge  in  all  kinds  of  recreation,  or  to  fill  an  active 
business  life  with  freedom  and  without  distress.  Under  these  circum- 
stances sudden  death  may  occur  without  warning,  and  it  is  this  fact, 
indeed,  which  causes  assuredly  the  popular  dread  which  prevails  about 
heart  disease. 

The  question  as  to  the  stationary  or  progressive  character  of  the  heart 
lesion  is  also  important.  From  this  point  of  view,  especially  among  old 
people,  aortic  regurgitation  would  appear  to  be  especially  dangerous, 
since  the  lesion  is  apt  to  advance  rapidly,  and  compensatory  hypertro- 
phy rarely  occur.  Here,  again,  I  have  seen  exceptions,  and  have  under 
my  care  a  notable  one  at  the  present  time.  Already  my  patient  is  an 
old  man,  and  the  aortic  regurgitant  lesion  is  very  marked ;  still,  in  several 
years  the  lesion  has  advanced  very  slightly,  if  at  all,  and  the  cardiac 
hypertrophy  is  very  considerable,  and  has  proved  in  the  main  satisfac- 
tory. At  present,  it  is  true,  my  patient  suffers  from  dyspnoea  upon  exer- 
tion, but  this  is  not  very  severe,  unless  he  overexerts  himself,  and  at  times 
it  is  due  to  his  somewhat  asthmatic  tendency,  and  is  more  under  the 
immediate  result  of  his  gouty  tendency  than  of  cardiac  weakness  from 
the  valvular  disease.  Murmurs  indicate,  as  a  rule,  the  valve  or  orifice 
affected,  but  do  not  show  the  gravity  or  the  state  of  the  lesion.  Dam- 
age to  orifice  or  valve  may  be  very  considerable,  and  yet  the  murmur 
may  be  very  low  and  soft.  We  may  have,  on  the  other  hand,  very  loud 
and  intense  murmurs  at  the  heart,  and  yet  the  cardiac  lesion  of  orifice 
or  valve  may  be  very  slight.  The  soft  murmur  may  depend  simply 
upon  the  weakness  of  the  heart  or  its  inability  to  produce  a  powerful 
vibratory  noise.  If  the  heart  gains  in  strength  and  vigor  the  murmur 
may  become  more  pronounced,  prolonged,  intense,  and  harsher.  When- 
ever the  murmur  is  post-systolic  or  post- diastolic  it  indicates  that  regur- 
gitation is  inadequate,  according  to  Broadbent,  and  that  the  heart  valves 
remain  together  only  a  very  short  time. 

In  many  of  these  cases  of  systolic  bruit  at  the  apex,  and  especially 


72  PROGNOSIS    IN    HEART    DISEASE. 

in  those  which  are  not  conducted  into  the  left  axilla,  and  are  somewhat 
permanent  in  character,  they  are  due  to  chronic  dilatation  of  the  heart, 
which,  from  the  point  of  view  of  the  prognosis,  is  far  more  important 
than  an  endocarditis  producing  mitral  regurgitation.  Frequently  the 
necropsy  shows  that  the  amount  of  endocarditis  is  small,  and  in  any 
event  does  not  satisfactorily  account  for  the  presence  of  great  heart 
weakness,  which  existed  previous  to  a  fatal  termination.  It  is  the 
amount  of  dilatation,  then,  of  the  ventricular  cavities,  combined  with 
more  or  less  hypertrophy,  which  is  the  really  important  condition,  and 
not  the  endocarditis  which  is  present  in  greater  or  less  degree. 

I  believe  that  what  Lees  says  so  well  in  speaking  of  children  is 
equally  true  of  adults :  "  Of  course,  the  regurgitation  at  the  mitral 
orifice  produces  increased  tension  in  the  left  ventricular  cavity  as  well 
as  in  the  left  auricular  cavity,  but  we  must  never  lose  sight  of  the  fact 
that  weakness  of  the  heart  muscle  makes  this  condition  serious,  and  not 
the  mere  valvular  insufficiency  which  precedes  therefrom,  or  may  be 
increased,  indeed,  somewhat  by  endocardial  inflammation.  In  children 
both  dilatation  and  endocarditis  may  be  of  rheumatic  origin."  The 
gravity  of  the  case  depends  more  upon  the  inflammatory  condition  of 
the  heart  muscle,  especially  in  children,  than  it  does  upon  the  concomi- 
tant valvular  affection.  Moreover,  the  frequency  of  rheumatic  carditis 
in  children  is  greater  than  in  adults.  If  carefully  managed  during  and 
subsequent  to  the  acute  rheumatic  attack,  a  fatal  result  does  not  ordi- 
narily follow,  at  least  in  the  beginning.  Later  on,  and  before  adult 
life  is  reached,  we  occasionally  meet  with  children  whose  hearts  are 
irrevocably  damaged  with  disease  of  progressive  nature,  and  do  what 
we  may,  death  surely  occurs  before  adult  life  is  attained.  In  the  his- 
tory of  such  cases  we  usually  find  several  pronounced  outbreaks  of 
acute  rheumatism.  At  the  autopsy  the  valvular  trouble  may  be  slight, 
or  pronounced,  but  in  any  event  the  heart  muscle  is  degenerated,  as 
shown  to  the  naked  eye  and  with  the  microscope.  If  the  mitral  valve 
be  affected,  as  it  commonly  is,  the  affection  is  rather  that  of  insuffi- 
ciency than  stenosis.  If  pericarditis  be  present  in  children  it  is  of 
more  importance,  as  a  rule,  than  the  endocardial  inflammation.  Owing 
to  the  intimate  relations  of  the  visceral  layer  of  the  pericardium  with 
the  heart  structure  beneath,  structural  changes  are  apt  to  extend  to 
and  implicate  considerably  the  heart  muscle,  either  causing  inflamma- 
tion or  degeneration  of  cardiac  fibres.  The  gravity,  as  Lees  observes, 
proceeds  in  these  instances  from  this  fact,  and  not  from  the  presence  of 
the  effusion  in  the  pericardium,  which  frequently  is  only  very  moderate 
in  degree.  We  can  readily  understand,  if  the  heart  muscle  become 
inflamed  or  degenerated,  that  the  power  of  the  heart  action  is  dimin- 
ished. With  this  diminution  of  power  there  ensue  dilatation  of  heart 
cavities  and  thinning  of  heart  walls.     Hence,  blood  accumulates  in  the 


PROGNOSIS    IN    HEART    DISEASE.  73 

ventricles  during  diastole,  and  is  not  expelled  as  it  should  be.  If  nutri- 
tion and  rest  of  the  child  be  suitably  and  continuously  provided  for, 
genuine  hypertrophy  of  heart  walls  may  ultimately  follow,  and  despite 
notable  cardiac  enlargement  the  heart  may  still  be  able  to  answer  satis- 
factorily to  its  requirements.  If  the  contrary  be  true,  viz.,  if  nutrition 
continue  at  a  low  ebb,  and  the  young  lad  or  girl  be  permitted  to  exer- 
cise or  play  imprudently,  the  hypertrophy  which  follows,  if  it  does 
follow,  is  of  the  pseudo  variety,  which  partakes,  indeed,  of  a  subacute 
or  chronic  inflammatory  character.  It  is  wise  to  bear  in  mind,  as 
has  been  more  than  once  insisted  upon,  how  important  it  is  to  combat 
properly  all  acute  or  chronic  manifestations  of  the  rheumatic  or  other 
poisons,  even  though  they  do  not  appear  at  the  time  to  have  notably 
affected  the  heart  so  far  as  auscultation  or  percussion  may  reveal.  I 
am  not  of  the  opinion  of  those  who  would  insist  upon  large  doses  of 
the  salicylates  or  other  so-called  anti-rheumatic  remedies,  because  I  do 
not  believe  that  their  apparent  curative  effects  are  always  obtained 
without  ultimate  real  injury  to  the  patient.  I  do  believe  that  the 
dietary  should  be  carefully  watched,  the  emunctories  of  the  economy, 
skin,  bowels,  and  kidneys  kept  in  good  functional  order,  and  when  the 
patient's  general  condition  permits  that  a  change  inland  from  the  sea- 
shore or  from  the  city  to  the  country  be  insisted  upon.  It  is  believed 
by  some  prominent  writers  that  the  differential  diagnosis  between  acute 
cardiac  dilatation  and  pericardial  effusion  is  readily  made.  In  my 
experience  this  diagnosis  is  very  difficult  at  times,  and  we  are  compelled 
to  fall  back  upon  what  we  know  of  the  results  of  autopsies  to  justify  us 
in  our  affirmations.  Usually  where  the  dilatation  has  come  on  rapidly, 
and  where  no  pericardial  friction  is  made  out,  the  probabilities  are  more 
in  favor  of  the  dilatation.  Again,  we  can  usually  distinguish  the  posi- 
tion and  strength  of  the  apex  beat  better  with  a  dilated  heart  than  we 
can  when  the  pericardial  sac  is  considerably  distended.  Weakness, 
irregularity,  and  rapidity  or  slowness  of  the  pulse  are  favorable,  in  my 
judgment,  to  a  diagnosis  of  dilatation.  In  chronic  cases  of  pericarditis 
where  the  two  layers  have  become  extensively  adherent,  or  adhesions 
have  been  formed  between  the  pericardium  and  the  pleura  or  medias- 
tinum, these  very  adhesions  prevent  the  heart  from  properly  contracting, 
and  thus  tend  greatly  to  increase  its  dilatation.  In  a  greater  degree 
even  this  is  probably  also  true  where  the  great  vessels  are  much 
constricted  by  old  adhesions. 

In  many  instances  of  acute  or  chronic  dilatation  of  the  heart  we  have 
a  mitral  murmur,  systolic  as  to  time.  If  this  murmur  be  conducted  to 
the  left  axilla,  doubtless  it  frequently  means  a  certain  amount  of  endo- 
cardial inflammation.  In  very  many  cases,  however,  it  is  a  mere  indi- 
cation of  the  cardiac  dilatation,  and  the  mitral  orifice  is  enlarged  simply 
because  the  left  ventricle  is  enlarged.     Such  instances  are  frequently 

6 


74  '    PROGNOSIS    IN    HEART    DISEASE. 

encountered  in  general  practice,  and  it  is  to  their  intelligent  appre- 
ciation and  treatment  that  curative  results  are  due  where,  without  this 
medical  acumen,  the  case  would  go  on  indefinitely  without  a  cure,  or 
suddenly  develop  phenomena  of  heart  failure,  which  are  alarming  for  a 
time,  and  only  benefited  by  a  systematic  rest  cure  and  judicious  man- 
agement under  the  care  of  a  wise  physician  and  tactful  trained  nurse 
in  the  course  of  six  months  or  longer.  In  the  society  girl  we  find  one 
notable  example  of  this  kind  of  cardiac  dilatation.  What  with  lunches, 
afternoon  teas,  dinners,  late  parties,  and  balls,  where  dancing  is  carried 
on  to  the  small  hours,  and  bed  only  reached  when  the  body  is  exhausted, 
no  wonder  that  loving,  anxious  mothers  come  pleadingly  to  the  family 
physician  for  relief.  The  girl  is  pale,  anaemic,  probably  constipated, 
leucorrhceic,  or  has  profuse  menses  ;  or  else  dysmenorrhoeic  or  amenor- 
rhoeic ;  she  is  always  more  or  less  fagged  out  and  tired.  She  sleeps 
until  ten  or  eleven  o'clock  in  the  forenoon,  takes  her  breakfast  in  bed, 
swallows  innumerable  Blaud's  pills,  because  haemoglobin  is  deficient 
and  the  corpuscles  pale,  even  though  the  blood  count  is  fairly  normal. 
The  urinary  secretion  is  often  colorless,  of  low  specific  gravity  ;  no  albu- 
min, no  sugar,  no  casts,  but  deficient  elimination  of  urea.  In  older 
persons  we  fear  interstitial  nephritis.  In  young  persons  experience  is 
consolatory,  and  we  know  rest,  moderate  massage,  oxygen  and  iron, 
beef  extracts  and  milk  punches  between  meals,  and  especially  some 
properly  formulated  cardiac  pill,  with  time,  produce  good  results, 
backed  up  with  early  hours,  plenty  of  sleep,  and  change  of  air.  These 
cases  occur  in  the  older  woman,  also  the  society  drudge,  who,  after  in- 
numerable social  engagements,  matinees,  and  evening  operas  thrown 
in  lavishly,  gives  way  finally,  gets  filled  up  with  stomachal  and  abdom- 
inal flatus,  becomes  dyspnoeic  on  slight  exertion,  has  heart  palpitation, 
and  blue  lips  and  finger  tips  in  the  very  acute  forms,  and  is  revived  at 
times  only  with  hot-water  bags,  mustard  plasters,  and  hypodermatics  of 
digitalis,  strychnine,  and  nitroglycerin.  The  urine  is  occasionally  loaded 
with  pink  urates,  and  pains  of  neuralgic  character  in  different  parts 
of  the  body  are  no  uncommon  features;  or,  again,  we  have  the  over- 
conscientious,  self-sacrificiug,  ever  tender,  loving,  and  far  too  devoted 
mother ;  she  it  is  who  holds  the  baby  at  night  when  sick  and  peevish, 
and  the  nurse  tired  out ;  she  it  is  who  looks  after  the  older  boys  and 
girls,  when  properly  they  should  care  for  themselves  and  for  her,  with 
ceaseless  solicitude.  She  buys  her  daughter's  dresses,  goes  with  her 
whenever  she  can  to  all  social  functions,  manages  her  household,  looks 
after  the  servants,  pays  the  bills,  runs  the  bank  account,  rarely  if  ever 
gets  a  good,  genuine  rest,  although  never  so  well  deserved,  and  one  day 
breaks  down  more  or  less  completely,  only  to  be  supported  temporarily 
with  cocoa  and  strychnine,  and  strophanthus  frequently  repeated.  I 
cannot  emphasize  all  these  cases  too  strongly.     They  are  not  overdrawn,. 


PROGNOSIS    IN    HEART    DISEASE.  75 

but  are  absolutely  true,  and  only  when  recognized  and  properly  cared 
for  does  the  medical  practitioner  get  the  beneficial  results  which  he 
most  desires.  Cardiac  dilatation,  vulgarly  termed  heart  failure,  is  the 
true  diagnosis,  and  this  condition  should  never  be  ignored. 

In  the  cases  to  which  I  refer  the  prognosis  is  always  graver  where 
there  have  been  previous  rheumatic  attacks  and  where  the  rheumatic 
poison  still  gives  indubitable  evidences  of  its  continued  presence,  for 
in  these  cases  we  must  dread,  and  properly  so,  the  hidden  effect  of  the 
toxin  of  this  disease  on  the  muscle  of  the  heart.  It  often  weakens  it 
through  structural  changes,  and  yet  the  cardiac  dilatation  may  not  be 
always  appreciable  to  our  physical  methods  of  exploration.  The  heart 
is  weak  in  its  action,  the  pulse  very  soft  and  depressible,  and  dyspnoeic 
attacks  show  themselves  upon  very  slight  exertion  or  whenever  the 
emotions  are  at  all  excited.  Such  patients  at  times  suffer  from  skin 
eruptions,  ambulant  neuralgia,  headaches,  constipation,  stomachal  indi- 
gestion, and  abdominal  flatus.  The  starches  are  very  inimical  to  them, 
as  also  all  sweets,  and  diets  should  consist  mainly  of  meat  for  many 
weeks,  despite  the  fact  that  for  lack  of  exercise  and  open  air  the  urine 
at  times  is  loaded  with  urates.  .Frequently  repeated  doses  of  calomel 
and  soda,  with  a  saline  purge  following,  is  the  best  and  safest  way  to 
combat  these  untoward  symptoms.  I  have  been  obliged,  in  addition,  to 
administer  heart  tonics  by  the  rectum  where  the  stomach  and  skin  were 
both  intolerant  for  a  while. 

Of  course  the  endocardium  may  be  inflamed  in  many  of  these  cases, 
and  we  may  discover  a  true  endocardial  bruit,  which  is  caused  by  the 
roughening  of  both  orifice  and  valves,  mainly  the  mitral.  But  the 
endocardial  bruit  is  not  what  should  alarm  us;  it  is  the  weakening  of 
the  heart  muscle  which  takes  place  at  the  same  time,  and  increases 
through  leakage  at  the  mitral  orifice  consequent  upon  dilatation,  the 
intensity  of  the  cardiac  bruit,  and  is  equally,  or,  more,  indeed,  the 
grave  expression  of  the  rheumatic  poison.  Again,  as  I  have  said  before, 
there  is  no  appreciable  bruit  at  first  near  the  apex,  merely  because  heart 
action  is  too  weak  to  cause  it,  and  later,  when  the  patient  is  doing  fairly 
well,  we  hear  the  blowing  murmur  very  readily.  One  of  the  difficult 
problems  in  practice  is  to  determine  accurately  the  presence  or  absence 
of  the  rheumatic  poison,  and  it  is  only  by  the  keen  appreciation  of  the 
patient's  previous  history  and  the  tentative  effects  of  anti-rheumatic 
remedies  that  we  may  fairly  obtain  a  conviction  about  it.  The  exami- 
nation of  the  urine  will  not  always  prove  it,  as  there  may  be  a  retention 
of  excrementitious  substances  in  the  economy,  which  only  repeated  and 
most  careful  urinary  analyses  made  under  like  conditions  would  deter- 
mine. As  to  the  symptoms,  these  are  frequently  of  such  indefinite 
character  that  we  might  easily  be  led  astray.  And  yet  sometimes  the 
most  powerful  heart  tonic   is  unquestionably  the    drug   or   drugs  which 


76  PROGNOSIS    IN    HEART    DISEASE. 

eliminate  the  rheumatic  poison  from  the  system  rapidly  and  without 
injuring  the  patient.  In  a  certain  number  of  cases  I  am  confident  that 
I  have  been  of  far  more  use  and  given  greater  relief  to  my  patient 
with  colchicin,  ealicin,  or  chloride  of  ammonium,  and  acetate  of  potash 
than  I  did  by  whipping  up  the  heart  action  directly  with  strychnine 
and  nitroglycerin. 

The  dulness  of  the  right  first  intercostal  space,  to  which  Rotch  has 
referred,  does  not  seem  to  prove  the  existence  of  pericardial  effusion  as 
opposed  to  true  dilatation  of  the  heart  cavities.  More  than  once  the 
hypodermatic  needle  has  been  used  to  determine  accurately  the  presence 
of  a  serous  effusion,  and  the  result  has  been  negative.  The  result  of 
post-mortem  examinations  would  also  tend  to  show  that  in  many  similar 
cases  the  heart  is  simply  enlarged  and  no  pericardial  effusion  is  present. 
Lees'  and  Broadbent's  observations  are  especially  corroborative  of  these 
facts. 

The  prognosis  of  heart  disease  is,  of  course,  much  influenced  by 
ambient  conditions  and  accidental  circumstances.  Wherever  the  cause 
producing  secondary  symptoms  of  heart  disease  is  one  which  we  have 
no  power  to  change  or  modify,  it  is  then  very  grave  indeed.  Where, 
however,  there  is  present  some  condition  which  we  can  fairly  hope  to 
eliminate  by  judicious  care,  then  our  confidence  is  much  greater  that 
we  can  help  our  patient  very  much.  How  often  do  we  see  an  anaemic 
girl  who  suffers  terribly  from  cardiac  distress  relieved  greatly  by  iron, 
mountain  air,  and  proper  exercise?  Or,  again,  if  the  aggravating 
cause  be  cold,  over-fatigue,  sudden  shock — all  these  accidental  circum- 
stances may  lose  their  pernicious  influence  with  treatment  and  time. 
It  has  long  been  recognized  that  the  mere  intensity  of  a  murmur  is  no 
indication  as  to  the  gravity  of  a  cardiac  lesion.  We  may  have  a  very 
loud  bruit,  and  yet  the  heart  lesion  is  really  slight.  On  the  other  hand, 
a  very  serious  change  of  orifice  or  valve  may  be  indicated  by  a  very 
low  bruit.  In  general  it  may  be  stated  that  it  is  the  amount  of  hyper- 
trophy or  dilatation  which  marks  the  gravity  of  the  murmur,  and  de- 
spite the  fact  that  frequently  the  enlargement  of  the  heart  is  also  a 
protective  power  against  secondary  symptoms,  which  we  most  dread. 
Prognosis  of  heart  disease  is  also  affected  by  the  stationary  or  progres- 
sive character  of  the  lesion.  As  we  know,  this  is  a  very  difficult  matter 
accurately  to  determine,  and  we  can  only  judge  of  the  one  or  other 
condition  by  the  manifestation  or  not  of  secondary  symptoms,  such  as 
pain,  palpitations,  and  dyspnoea,  not  to  speak  of  the  physical  evidences 
with  which  we  are  all  too  sadly  familiar.  Circumstances  outside  of  the 
heart  influence  prognosis ;  these  are  age,  sex,  occupation,  heredity,  etc. 

Heart  disease  is  certainly  graver  in  youth  than  it  is  in  middle  life. 
Structural  defects  of  the  heart  muscle  are  not  infrequently  inherited. 
A  laborious  life,  or  one  full  of    cares  and   anxieties,  aggravates    very 


PROGNOSIS    IN    HEART    DISEASE.  77 

much  the  prognosis,  whereas  a  life  of  ease  is  productive  of  a  stationary 
effect  in  the  development  of  symptoms  of  heart  disease.  Serous  effu- 
sions into  the  large  cavities  indicate  gravity.  This  is  greater  with 
aortic  than  mitral  disease.  It  is,  also,  of  more  serious  import  where 
the  effusions  come  on  insidiously  than  where  they  develop  after  a  sud- 
den shock  or  accident.  It  is  probable,  in  many  instances,  that  the  mere 
presence  of  organic  heart  disease  does  not  materially  shorten  life  or 
interfere  notably  with  its  reasonable  enjoyment  or  with  the  fulfilment 
of  one's  duties  and  responsibilities.  I  have  taken  care  of  several  old 
men  and  women  who  have  unquestionably  had  mitral  or  aortic  disease 
during  a  greater  portion  of  their  adult  life,  and  who  nevertheless  lived 
to  an  advanced  age.  Moreover,  not  infrequently,  they  have  been  very 
little  annoyed  from  their  heart  affection,  and  very  rarely  suffered  from 
symptoms  directly  attributable  to  it.  Even  when  such  secondary  symp- 
toms did  occur,  through  carelessness  or  undue  exposure,  by  a  short  course 
of  judicious  treatment  they  were  soon  again  enjoying  their  usual  health. 
There  is  a  proper  application  here  to  the  conduct  of  insurance  com- 
panies. Some  of  these  companies  refuse  to  take  any  cases  of  heart  dis- 
ease ;  others  do  so,  but  charge  them  a  larger  premium.  Wherever  there 
are  no  secondary  symptoms  of  heart  disease  or  evidences  of  disease  of 
other  organs,  it  seems  to  be  wisdom  to  accept  such  cases  in  the  latter 
way  as  a  proper  business  venture. 

Cardiac  enlargement,  which  in  adolescent  and  adult  life  is  most  fre- 
quently under  the  dependence  of  obstructive  or  regurgitant  disease  of 
one  or  the  other  orifice,  is  often  accompanied  in  old  age  with  disease  of 
the  arteries.  The  arterial  changes  are  sufficient  of  themselves,  if  not 
to  cause  intracardiac  changes,  at  least  to  increase  them  when  they  have 
begun.  Sometimes  the  myocardial  degeneration  connected  with  the 
increased  size  of  the  heart  gives  proof  of  its  presence  by  distressing 
symptoms.  Not  infrequently,  however,  these  changes  exist  for  a  shorter 
or  longer  period  without  manifesting  their  existence  except  by  symp- 
toms which  indicate  little  or  no  gravity  to  the  family  physician.  It  is 
only  when  some  really  alarming  symptoms  declare  themselves  that 
anxiety  of  near  relatives  and-friends  is  awakened.  I  have  also  known 
several  cases  in  which  sudden  death  occurred  in  which  previously  the 
patient  had  usually  enjoyed  a  very  fair  degree  of  health  and  activity. 
Sometimes,  it  is  true,  that  some  cardiac  pain,  either  spontaneous  or 
occurring  after  moderate  exertion,  of  a  pseudo-anginal  type,  had  occa- 
sionally been  present,  and  yet  no  undue  anxiety  either  of  patient  or  of 
loved  ones  had  developed.  At  the  necropsy  of  such  patients  myocar- 
dial changes  more  or  less  extensive  are  readily  made  out,  even  with  the 
naked  eye.  The  coronary  arteries  are  frequently  inelastic,  hard,  cal- 
careous, or  atheromatous.  In  their  immediate  area  of  distribution,  and 
particularly  near  their  trunks  and  about  the  inter-ventricular  septum, 


78  PROGNOSIS    IN    HEART    DISEASE. 

cardiac  fibres  are  already  indistinct,  pale,  and  fatty.  Usually  such 
changes  are  accompanied  by  notable  cardiac  dilatation.  It  is  probable 
that  if  the  symptoms  of  these  conditions  prior  to  death  be  properly 
estimated  much  may  be  done  to  ameliorate  the  patient's  condition,  to 
relieve  suffering,  and  doubtless  at  times  to  prolong  life  and  one's  use- 
fulness very  much.  There  are  instances,  however,  of  the  senile  heart 
with  unquestionable  enlargement  which  during  life,  and  for  many  years, 
have  never  given  rise  to  any  unpleasant  symptoms,  and  are  only  re- 
vealed in  an  accidental  way  when  the  patient  is  examined  by  a  physi- 
cian for  some  entirely  different  affection. 

More  or  less  precordial  pain  is  one  of  the  first  symptoms  which  directs 
attention  to  the  failing  heart  of  the  aged.  This  pain  may  be  slight  at 
first,  and  slowly  increase,  usually  in  an  intermittent  manner,  or  it  may 
develop  suddenly  and  with  great  intensity.  In  the  latter  instance, 
ordinarily,  it  follows  overexertion,  severe  mental  shock,  or  exposure. 
It  is  accompanied  with  marked  intermittence  or  irregularity  of  both 
pulse  and  heart  beats.  These  symptoms  may  be  temporary  or  lasting. 
Whenever  they  come  on  suddenly,  and  where  some  accidental  circum- 
stance sufficiently  explains  their  advent,  we  may  be  hopeful  that  with  judi- 
cious care  they  will  disappear  sooner  or  later.  Where,  on  the  contrary, 
they  have  developed  slowly  and  somewhat  insidiously,  they  are  of  seri- 
ous augury,  and  usually  indicate  intracardiac  changes,  which  will  prob- 
ably lead  to  the  development  of  even  graver  symptoms.  Wherever 
the  lower  limbs  become  oedematous  and  the  serous  cavities  contain  fluid 
in  notable  quantity  it  is  very  seldom  that  any  therapeutic  agents  can 
ward  off  the  approaching  fatal  termination  for  many  months.  We 
must  insist,  therefore,  upon  the  great  importance  of  watching  carefully 
the  first  expression  of  cardiac  inadequacy  in  old  age,  and  guard  against 
its  rapid  increase  by  such  means  as  we  have  at  our  disposal.  In  this 
place  I  wish  to  direct  attention  to  a  formula  which  has  long  been 
known  as  the  diuretic  wine  of  the  Hotel  Dieu,  or  Trousseau's  wine. 
It  is  essentially  composed  of  digitalis,  squills,  juniper  berries,  acetate 
of  potash,  and  white  wine.  In  dessert  or  tablespoonful  doses,  repeated 
from  three  to  eight  times  in  twenty-four  hours,  I  have  seen  it  occasion- 
ally effect  temporary  good  results  which  were  very  remarkable.  Indeed, 
I  have  known  it  occasionally  to  effect  a  cure  which  lasted  several  years, 
where  the  patient  was  seemingly  before  its  use  (and  where  many  other 
combinations  had  been  previously  resorted  to  without  avail)  in  a  very 
critical  condition.  Cardiac  palpitations  and  tremor  cordis  are  symp- 
toms of  the  senile  heart  which,  although  distressing,  do  not  as  a  rule 
augment  the  gravity  of  prognosis.  It  is  a  singular  fact  that  cardiac 
palpitations  do  not  affect  old  people  nearly  so  often  as  they  do  the 
young.  Is  this  due  to  the  greater  impressionability  of  adolescents,  and 
particularly  young  women  ?     Tachycardia  may  be  due  to  some  poison, 


PROGNOSIS    IN    HEART    DISEASE.  79 

like  alcohol,  tobacco,  tea,  or  coffee,  affecting  the  pneuraogastric  and 
diminishing  its  restraining  influence.  In  such  instances  a  prolonged 
period  of  abstinence  will  usually  effect  a  decided  improvement,  and  not 
infrequently  a  permanent  cure.  There  are  instances,  however,  in  which 
the  nervous  poison  has  become  so  deep-seated  that  the  distress  and  dis- 
ability to  the  patient  are  never  entirely  gotten  rid  of.  Of  course, 
where  the  increased  action  of  the  heart  is  dependent  upon  structural 
changes,  already  clearly  manifest  in  the  heart  itself,  we  cannot  properly 
expect  long-continued  benefit  from  any  remedial  agents,  although  even 
here  we  should  always  be  willing  to  recognize  how  imperfect  our  mere 
physical  explorations  may  be,  and  how  often  our  deductions  therefrom 
are  later  on  invalidated  by  the  patient's  evident  improvement.  I  can- 
not emphasize  too  strongly  the  fact  that  we  should  never  despair,  even 
in  advanced  years,  to  secure  benefit  more  or  less  lasting  by  the  wise  use 
of  remedies.  Not  that  we  actually  delay  or  prevent  the  advance  of 
serious  disease  in  these  very  grave  cases,  but  we  certainly  do  at  times 
give  most  pronounced  relief  to  the  mere  functional  disablement,  and 
this,  after  all,  is  the  great  role  of  the  practitioner  in  cardiac  thera- 
peutics. 

I  am  thoroughly  persuaded  that  very  many  physicians  err  grievously 
in  their  use  of  the  so-called  cardiac  tonics.  Very  often  they  are  given 
in  too  large  doses ;  again,  they  are  given  in  combinations  which  are 
unintelligent,  mainly  because  they  are  "shot-gun"  prescriptions,  with- 
out a  definite  idea  as  to  what  they  are  doing  ;  and,  finally,  because  no 
proper  appreciation  is  paid  to  the  physiological  effects  of  combining 
remedies  which  possibly  neutralize  one  another's  beneficial  action.  Small 
doses  frequently  repeated,  simple  remedies  in  a  thoroughly  assimilable 
form — these  should  be  essential  considerations  in  our  prescribing. 
Whenever  we  endeavor  too  suddenly  to  give  power  to  an  already  over- 
taxed heart  the  danger  is  evident  that  we  often  actually  overstep  the 
mark  and  cause  directly  a  fatal  termination,  while  with  keener  medical 
insight  we  should  be  really  useful.  The  bearing  of  the  preceding  re- 
marks upon  prognosis  is  clear.  Heart  disease,  not  necessarily  threaten- 
ing, managed  foolishly  by  a  tyro  or  an  ignoramus,  may  become  very 
grave,  and  imminently  so.  Heart  disease,  similar  in  degree  and  char- 
acter, managed  by  the  wise,  censervative  practitioner,  has  a  wholly 
different  outlook.  It  is  too  much  the  fashion  of  our  time  in  matters  of 
medicine  to  believe  that  the  same  remedies  given  by  two  different  men 
will  effect  the  same  result.  They  will  do  nothing  of  the  sort.  Take  a 
very  ordinary  illustration,  and  yet  one  which  strikes  the  mind  forcibly, 
from  a  very  different  sphere— viz.,  the  cook  and  cookery. 

A  French  chef,  with  his  savant  gastronomic  tastes  and  education, 
will  produce  from  a  few  simple  materials  an  excellent,  appetizing,  nour- 
ishing dish.     An   ignorant,  self-satisfied,  and   hence   daring   cook    will 


80  PROGNOSIS    IN      HEART    DISEASE. 

usually  spoil  and  make  utterly  uneatable  and  most  indigestible  dishes 
from  the  very  same  viands.  So  it  is  with  good  and  bad  practitioners  in 
affections  of  the  heart.  In  the  one  case  we  see  amelioration,  great  and 
enduring,  perhaps,  effected ;  under  different  care  the  downward  path  is 
rapid  and  certain.  In  instances  where  we  have  marked  cardiac  slow- 
ness the  intracardiac  changes  are  more  frequent  than  where  the  heart 
action  is  unduly  rapid.  On  this  account  this  condition  carries  with  it 
ordinarily  a  graver  prognosis.  In  many  instances,  fortunately,  the 
gouty  dyscrasia  seems  measurably  to  affect  the  slowness  of  the  heart 
beat,  and  by  proper  eliminative  remedies  we  can  often  accomplish  excel- 
lent results.  I  am  confident  torpidity  of  the  liver  in  many  such  cases 
is  a  primary  factor  in  this  slow  heart  action.  The  portal  circulation 
becomes  clogged,  and  the  more  easily,  no  doubt,  on  account  of  inter- 
stitial changes  which  are  present  in  the  liver,  just  as  they  are  in  the 
kidneys,  and  are  but  a  development  of  structural  conditions  that  age 
produces  almost  of  necessity. 

Give  minute  doses  of  calomel  and  soda,  gray  powder,  several  times 
repeated  in  the  course  of  a  week  or  two,  and  soon  everything  which 
caused  immediate  anxiety  is  often  greatly  improved.  For  a  long-con- 
tinued course  of  treatment  it  is  wisdom  to  abandon  the  mercurials,  and 
institute  in  their  place  frequent  doses  of  podophyllin,  ipecac,  soda,  and 
rhubarb.  After  such  course  we  shall  often  see  senile  hearts  practically 
rejuvenated  for  a  time  at  least,  and  a  new  lease  of  life  and  its  enjoy- 
ment quietly  entered  upon.  In  certain  examples,  where  the  gouty  ten- 
dency is  clearly  defined,  and  where,  particularly,  symptoms  of  angina 
may  be  present,  I  would  insist  upon  the  use  of  Contrexeville  water.  I 
esteem  that  the  profession  is  under  obligations  to  Dr.  D'Estrees  for  his 
advocacy  of  this  water,  and  already  in  my  experience  I  have  seen  sev- 
eral cases  in  which  the  gouty  condition  has  been  favorably  modified  in 
a  very  striking  manner  by  its  continued  use  for  many  weeks.  The 
elimination  of  uric  acid  from  the  economy  by  its  action  seems  at  times 
exceptionally  great.  In  all  cases  of  senile  heart  our  prognosis  should 
be  carefully  guarded,  and,  as  Balfour  says,  we  must  shrink  from  dog- 
matism. If  we  make  too  positive  statements  as  to  the  immediate  out- 
come of  the  disease  we  are  very  liable  to  be  mistaken.  There  are 
usually  so  many  modifying  and  attendant  factors  to  change  influencing 
conditions  that  we  should  add  extreme  caution  to  our  every  assertion. 


MINOR  FORMS  OF  CARDIAC  DILATATION.1 


Cardiac  dilatation  in  a  pronounced  degree,  due  either  to  organic 
valvular  disease  or  to  obvious  myocarditis — acute  or  chronic — is  no 
doubt  recognized  and  properly  treated  by  the  average  good  and  care- 
ful clinician.  This  affection  in  its  minor  degree  is  frequently  con- 
founded with  some  other  ailment,  or  when  recognized  not  given  its 
due  importance,  and  hence  ignored  so  far  as  active  direct  treatment 
is  concerned.  Cardiac  dilatation  when  at  all  advanced  may  usually  be 
recognized,  as  we  know,  by  the  usual  methods  of  physical  examination. 

Percussion  shows  increased  cardiac  dulness,  especially  in  a  lateral 
direction ;  palpation  finds  the  heart  impulse  lessened  in  force,  more  dif 
fuse,  and  the  locality  of  the  apex-beat  often  somewhat  changed,  and 
not  always  readily  determined.  Inspection  corroborates  these  findings 
more  or  less  well.  The  use  of  the  stethoscope  in  addition  reveals  feeble, 
irregular  heart  sounds.  The  two  sounds  of  the  heart  resemble  one  an- 
other more  nearly — the  long  pause  is  shortened.  We  may  or  may  not 
have  a  soft  blowing  murmur  at  the  apex  of  the  heart,  and  this  murmur, 
usually  systolic,  may  also  be  diastolic.  The  pulse  is  rapid,  irregular, 
depressible,  as  a  rule.  It  may  be  very  infrequent.  Dyspnoea,  palpita- 
tions, and  occasional  precordial  pain  as  symptoms  of  cardiac  dilatation 
are  not  unusual.  Now  and  then  we  have  in  most  pronounced  cases 
blueness  of  lips  and  fingers,  obstructed  general  venous  circulation,  and 
oedema  of  the  lower  limbs.  The  foregoing  is  a  brief  picture  of  cardiac 
dilatation  in  its  advanced  stage. 

As  I  meet  it  in  minor  forms  in  my  daily  rounds  of  practice  it  does 
not  appear  precisely  after  the  manner,  and  I  have  been  often  misled  as 
to  its  presence  and  significance.  One  very  ordinary  type  is  that  of  the 
anemic  girl  just  past  the  age  of  puberty.  She  suffers  often  from  too 
profuse  menstruation,  constipated  bowels,  and  gaseous  eructations  from 
the  stomach ;  she  has  little  or  no  appetite,  and  is  constantly  tired  and 
nervous.  The  heart  fluttering  and  irregularity  (subjective),  which  goes 
with  these  symptoms  we  recognize,  and  yet  how  seldom  do  we  consider 
the  heart  action  in  these  instances  as  being  indicative  of  organic  change 
which  must  be  treated  properly  and  effectually  if  we  are  to  obtain  good 
curative  results.  Such  cases  require  iron  and  oxygen,  rest  and  massage, 
proper  diet,  and   restricted  hours  of  mental  effort.     They  also  require 

1  Read  before  the  Association  of  American  Physicians,  Washington,  1900. 


82  MINOR    FORMS    OF    CARDIAC    DILATATION. 

still  more,  and  in  the  beginning  of  treatment  it  is  absolutely  essential, 
small  repeated  doses  of  digitalis  and  nux  vomica  until  their  hearts 
respond  forcibly  or  at  least  with  power  sufficient  to  enable  us  to  make 
satisfactory  use  of  the  other  means  to  restore  bodily  activity.  How 
shall  we  recognize  such  cases  ?  Oftentimes  with  much  difficulty,  unless 
we  appreciate  rather  obscure  clinical  facts.  There  is  no  diffuse  or 
weakened  cardiac  impulse.  On  the  contrary,  the  heart  apex-beats  in 
the  fifth  interspace  below  and  inside  the  nipple  line.  It  may  be  of 
good  force  and  not  at  all  irregular.  Abnormal  sounds  are  not  always 
present.  There  may  not  be  any  marked  accentuation  of  the  second 
sound.  As  a  rule,  however,  the  action  of  the  heart  is  more  frequent 
than  normal,  and  the  first  sound  is  exaggerated,  seemingly  irritable. 
Give  these  patients  for  a  week  or  two  digitalis  and  strychnine  in  mod- 
erate doses,  and  follow  them  with  a  prolonged  course  of  iron,  and  we  get 
our  best  results.  Act  differently,  and  we  are  disappointed  in  our  effort, 
time  and  again,  to  relieve  symptoms  and  improve  the  general  health. 

One  of  the  proofs,  as  I  believe,  which  show  the  correctness  of  my 
diagnosis  is  that  frequently  in  these  cases  the  urine  is  light  colored,  of 
low  specific  gravity,  containing  neither  albumin  nor  casts,  and  it  may  or 
may  not  be  in  sufficient  quantity.  Rest  in  bed  will  change  this  urine 
so  far  as  color,  density,  quantity,  and  the  elimination  of  urinary  solids 
are  concerned.  It  will  also  be  effected  and  more  rapidly  sometimes  with 
rest,  sometimes  without,  by  the  use  of  suitable  cardiac  tonics  in  very 
moderate  doses. 

I  know  such  a  condition  is  often  attributed  to  impairment  of  the 
nervous  tone,  or  perhaps  to  hysteria.  So,  indeed,  it  is  at  times,  but 
behind  this  frequently  is  the  loss  of  a  certain  amount  of  cardiac  mus- 
cular power.  The  cavities  of  the  heart  are  doubtless  slightly  enlarged, 
and  particularly  that  of  the  left  ventricle,  and  the  walls  thinned.  There 
is  no  hypertrophy,  and  why  ?  Simply  because  there  is  not  sufficient 
vital  energy  to  produce  it.  The  power  of  the  heart  can  only  be  increased 
in  one  or  two  ways :  by  general  corroborant  treatment,  or,  at  first,  by 
suitable  cardiac  stimulation,  and  subsequently  followed  by  the  second. 
The  latter  plan  is  the  speedier  and  better  one,  as  I  believe. 

Formerly  in  some  of  these  cases  I  was  at  times  in  reasonable  doubt 
for  a  while  as  to  whether  I  had  to  do  with  beginning  renal  changes  of 
interstitial  nephritis.  The  age  of  the  patient,  the  anaemic  state,  and 
the  rapid  effects  of  judicious  treatment  settle  all  reasonable  doubts  very 
soon  at  the  present  time  in  the  great  majority  of  cases.  In  these 
instances  is  the  heart  muscle  structurally  affected  ?  Is  there  granular  or 
other  degeneration  of  cardiac  fibres  ?  I  do  not  believe  so,  at  least  in 
the  great  number  of  examples,  in  view  of  the  success  of  treatment  after 
several  weeks  or  months.  In  other  instances,  where  there  is  little  or  no 
favorable  response  to  rational  medication,  change  of  air  and  nursing, 


MINOR     FORMS    OF    CARDIAC    DILATATION.  83 

and  where  the  examination  of  the  blood  by  an  expert  shows  signs  that 
indicate  a  formidable  anaemia  feigning  the  pernicious  form,  I  am  con- 
vinced that  we  have  to  do  with  parenchymatous  changes  of  the  myo- 
cardium of  more  or  less  grave  import. 

Is  there  any  method  by  which  we  can  demonstrate  these  changes  to 
the  skeptical  duriug  life?  Certainly  not.  All  we  can  do  is  to  reason 
from  analogy  and  our  pathological  findings  in  more  serious  states  which 
go  on  to  a  fatal  termination.  Fortunately,  the  overworked  shop  girl,  or 
the  tired-out  society  young  lady,  when  she  gets  the  care  required,  ulti- 
mately, and  as  a  rule,  gets  fairly  well.  I  have  no  doubt  in  my  own 
mind  that  in  many  instances  perfected  development  or  full-growth  of 
body  reached  from  the  twentieth  to  the  twenty-fifth  year  explains  the 
happy  termination  of  some  cases.  In  other  words,  these  cases  in  a 
measure,  may  be  self-limited.  To  the  unconvinced  listener  who  would 
call  such  cases  merely  functional,  I  would  answer :  if  they  are  then  the 
words  of  Sir  Andrew  Clark  apropos  of  another  topic  seem  to  be  singu- 
larly suggestive  and  true : 

"We  are,"  writes  Clark,  "so  much  concerned  with  anatomical 
changes ;  we  have  given  so  much  time  to  their  evolutions,  differentia- 
tions, and  relations ;  we  are  so  much  dominated  by  the  idea  that  in 
dealing  with  them  we  are  dealing  with  disease  in  itself  that  we  have 
overlooked  the  fundamental  truth  that  these  anatomical  changes  are  but 
secondary  and  sometimes  the  least  important  expressions  or  manifesta- 
tions of  states  which  underly  them.  It  is  to  these  dynamic  states  that 
our  thoughts  and  inquiries  should  be  turned  ;  they  precede,  underly, 
and  originate  structural  changes ;  they  determine  their  character, 
course,  and  issues  ;  in  them  is  the  secret  of  disease,  and,  if  our  control 
of  it  is  ever  to  become  greater  and  better,  it  is  upon  them  that  our 
experiments  must  be  made."  1 

Another  form  to  which  I  would  direct  attention  is  that  of  the  some- 
what obese  woman — married  or  unmarried — between  forty  and  fifty 
years  of  age.  Not  infrequently  these  women  have  a  marked  rheumatic 
tendency.  Not  infrequently  their  urine  on  cooling  deposits  an  excess 
of  urates  of  uric  acid.  They  often  have  slight  attacks  of  bronchitis, 
ambulatory  neuralgic  pains,  localized  dry  pleurisy.  When  in  their 
usual  health  they  can  take  moderate  exercise  without  great  distress. 
So  soon  as  they  have  any  acute  ailment  or  depletion  they  suffer  from 
marked  difficulty  of  breathing,  a  gone  feeling  at  the  epigastrium,  and 
an  inward  sense  of  suffocation,  as  they  express  it.  Usually  their  cardiac 
action  is  feeble,  rapid,  and  slightly  irregular  under  these  circumstances. 
Physical  examination  may  or  may  not  reveal  at  this  time  a  soft  blowing 
murmur,  systolic  as  a  rule,  often  heard  with  greatest  intensity  in  the 

i  British  Medical  Journal,  August  16,  1884,  p.  312. 


84  MINOR    FORMS    OF    CARDIAC    DILATATION. 

mitral  area,  but  also  heard  at  times  in  the  left  intercostal  spaces  above 
the  nipple  or  at  the  lower  end  of  the  sternum.  The  blood  may  or  may 
not  show  a  moderate  degree  of  anaemia.  Duriug  and  after  their  men- 
strual epochs  these  patients  are  often  at  their  worst,  and  whenever  the 
flow  is  abundant  their  condition  inspires  great  solicitude.  They  do  not 
always  have  fever  when  they  have  their  slight  bronchitis  or  pleuritic 
attacks.  At  other  times  the  temperature  rapidly  goes  to  102°  or  even 
higher,  and  areas  of  local  pulmonary  congestion  are  accurately  made 
out.  Such  cases  are  amenable  to  judicious  treatment,  and  in  the  course 
of  ten  days  or  two  weeks  very  great  temporary  improvement  will  take 
place.  I  usually  give  very  small  repeated  doses  of  nux  vomica  and 
strophanthus  in  the  beginning  of  these  attacks.  I  insist  upon  rest  in 
bed  and  frequent  small  quantities  of  liquid  or  easily  digested  food. 
Where  there  are  cough  and  local  signs  of  dry  pleuritis  a  small  fly- 
blister,  though  painful,  is  a  sovereign  remedy.  Of  course,  the  men- 
strual flow  when  excessive  should  be  controlled  with  ergot  or  hot 
douches. 

In  some  of  these  cases  where  there  is  also  well-marked  anaemia  there 
is  present  at  times  and  in  a  more  or  less  continuous  manner  a  small 
amount  of  albumin  in  the  urine.  The  clinical  examination  of  the  urine 
is  such  that  I  have  known  patients  of  this  sort  to  be  told  that  they  were 
suffering  from  nephritis,  and  it  was  essential  for  them  to  live  during  a 
long  period  upon  a  milk  diet,  and  to  reside  in  an  equable,  dry,  and  rela- 
tively mild  climate.  In  these  cases  the  albumin  would  at  times  disap- 
pear, but  fatigue,  indiscretions  of  food,  temporary  excitement  would 
apparently  bring  back  the  albuminuria.  I  have  no  doubt  the  kidneys 
were  affected  with  chronic  congestion.  I  am  also  very  confident  that  the 
hypersemia  was  passive  rather  than  active,  and  was,  in  reality  and 
mainly  under  the  dependence  of  a  weak  heart,  quite  insufficient  in  its 
action  to  keep  up  a  proper  vascular  tension  in  the  renal  arteries.  Here, 
again,  judicious  cardiac  treatment  was  essential  at  first.  With  the  digi- 
talis or  strophanthus,  however,  I  usually  combine  a  small  quantity  of 
nitroglycerin,  as  I  deem  it  very  important  to  dilate  the  peripheral  cir- 
culation and  thus  lessen  the  necessary  work  of  the  heart  to  become 
effective. 

There  is  another  type  of  woman,  and  she  is  usually  thin  and  nervous 
about  the  time  of  the  climateric  or  past  it.  The  menstrual  flow  if  it 
still  exists  is  slight.  These  patients  may  not  be  anaemic  to  any  appre- 
ciable extent.  They  have  frequently  very  imperfect  digestive  assimila- 
tion. They  may  have  some  dilatation  of  the  stomach,  and  are  frequently 
nauseated  and  unable  to  take  even  the  simplest  forms  of  food  for  a  time 
without  causing  great  and  rapid  gaseous  distention,  not  only  of  the 
stomach,  but  also  of  the  bowels.  The  liver  is  inactive  and  the  bowels 
are  torpid.     We  can  give  few  medicines  by  the  mouth  except  stomach- 


MINOR    FORMS    OF    CARDIAC     DILATATION.  85 

ica  and  carminatives  without  making  their  condition  worse.  Although 
their  heart  is  extremely  feeble,  so  much  so  at  times  in  fact  that  we  dread 
almost  to  move  or  raise  them  to  make  a  proper  exploration  of  the  chest, 
yet  if  we  so  much  as  try  to  use  any  medication  by  the  mouth  to 
strengthen  heart  action  we  shall  almost  surely  bring  on  worse  distress 
and  perhaps'  excessive  nausea  and  repeated  vomiting.  I  have  been 
obliged  to  treat  such  a  patient  for  days  at  a  time  with  digitaline  and 
strychnine  hypodermatically,  while  inhalations  of  oxygen  were  fre- 
quently administered.  Rectal  alimentation  with  panopepton,  pepton- 
ized milk,  egg,  brandy,  and  a  little  opium  at  times  took  the  place 
almost  entirely  of  feeding  by  the  mouth  for  several  days.  Where  the 
repeated  use  of  the  hypodermatic  syringe  set  up  local  irritation  I  was 
obliged  to  incorporate  my  cardiac  stimulants  with  very  small  rectal 
enemata  of  water.  Finally,  after  weeks  of  anxiety  and  constant  nurs- 
ing and  unremitting  attention,  these  women  slowly  regained  their  health 
and  strength,  and  the  heart  became  sufficiently  strong  to  satisfy  ordi- 
nary demands  made  upon  it  when  the  patient  went  about  in  a  very 
limited  measure.  The  urine  never,  upon  repeated  examinations,  showed 
either  albumin  or  sugar,  but  did  show  low  specific  gravity,  deficient 
elimination  of  urea,  and  perhaps  a  few  hyaline  or  granular  casts.  I 
could  not  positively  affirm  any  general  arterio-fibrosis.  I  could  and 
did  strongly  suspect  its  presence.  The  heart  gave  all  the  evidences  of 
slight  dilatation  of  the  ventricular  cavities,  but  at  no  time  was  there 
any  manifest  hypertrophy.  In  some  patients  there  was  rarely  any 
cardiac  murmur,  and  all  I  could  detect,  as  a  rule,  was  great  feebleness 
of  heart  action  without  irregularity  or  intermissions.  I  have  no  doubt, 
for  my  part,  that  if  these  hearts  were  examined  post-mortem  they  would 
show  few  or  no  changes  other  than  those  which  follow.  They  would  be 
soft  and  flabby.  They  would  not  retain  their  rounded,  globular  form, 
but  would  flatten  on  the  table  through  partial  collapse  of  the  walls. 
There  would  be  no  valvular  changes.  The  orifices  might  be  slightly 
dilated.  There  would  be,  as  stated  already,  slight  enlargement  of  the 
cavities  and  thinning  of  the  muscular  walls.  The  color  of  the  heart 
muscle  would  approximate  that  of  the  faded  leaf;  perhaps,  usually  it 
would  only  be  relatively  pale  and  bloodless.  The  cavities  would  con- 
tain small,  imperfectly-formed  post-mortem  clots  or  liquid  blood.  Under 
the  microscope  we  should  find  the  strise  here  and  there  imperfectly 
marked.  There  would  possibly  be  some  well-marked  granular  degenera- 
tion at  times,  and  only  very  rarely  the  evidence  of  fatty  degeneration. 
If  the  latter  existed  it  would  more  likely  be  in  patches  in  the  capillary 
muscles,  the  septum,  or  the  ventricular  walls  than  generally  diffused. 

Unfortunately,  these  are  at  best  clinical  impressions  rather  than  well- 
ascertained  facts.  And  why  ?  Simply  because  post-mortem  examina- 
tions of  these  cases  are  not  made.    The  patients  do  not  die,  in  my  expe- 


86  MINOR    FORMS    OF    CARDIAC    DILATATION. 

rience,  at  least  outside  of  hospitals.  In  hospitals,  when  they  die,  they 
have  more  advanced  and  graver  phenomena  of  a  similar  condition,  and 
then  it  is  we  can  surely  and  positively  affirm  what  our  findings  are. 

In  many  instances  I  have  had  a  report  from  the  pathologist  which  in 
its  main  features  was  not  unlike  what  I  have  attempted  to  describe.  In 
this  connection  I  would  refer  to  a  paper  of  Dr.  Danforth,  of  extreme 
interest  to  me,  read  at  the  last  meeting  of  this  Association,  on  "  Clinical 
Forms  of  the  Uric-acid  Diathesis."  It  seems  to  me  that  some  of  Dr. 
Danforth's  cases  may  have  been  mainly  instances  of  cardiac  dilata- 
tion, in  which  the  renal  manifestations  were  merely  a  resultant  of  a  weak, 
feeble  heart  action.  At  all  events,  I  have  portrayed  the  other  side  of  a 
clinical  picture  frequently  encountered  by  myself.  I  do  not  wish  to  con- 
vey the  impression  that  I  have  made  a  new  discovery — such  cases  as 
mine  are  met  with  by  all  of  you.  They  are  also  described  more  or  less 
perfectly  in  almost  every  text-book  of  cardiac  disorders  of  the  last  fifty 
years.  Still  I  am  free  to  confess  that  I  do  not  know  precisely  where  you 
will  find  the  clinical  picture  I  have  endeavored  to  delineate  in  quite 
the  same  terms. 

I  may  be  asked  whether  I  do  not  find  these  cases  also  among  men. 
Perhaps  I  do,  but  I  do  not  recall  them  in  such  a  vivid  manner  as  to  be 
able  to  portray  them.  The  laboring  man,  even  though  he  may  never 
suffer  from  actual  valvular  disease,  will  undoubtedly  have  at  times 
marked  cardiac  dilatation.  But  usually  there  is  more  or  less  hyper- 
trophy combined  with  it,  and,  even  though  the  heart  has  become  very 
incompetent  through  structural  weakness,  there  will  be  such  considerable 
enlargement  that  we  feel  confident  that  the  autopsy  will  show  more  or 
less  thickening  of  heart  walls.  The  same  is  true  of  old  valvular  disease 
accompanied  with  cardiac  enlargement.  It  is  equally  true,  as  a  rule, 
where  the  history  shows  that  there  has  been  a  persistent  and  excessive 
alcoholic  habit.  This  is  true  also,  although  in  less  degree,  of  the  busi- 
ness or  professional  man  affected  with  heart  disease. 

Extreme  cases  of  heart  dilatation  and  no  hypertrophy  are  also  met 
with  among  men ;  but  the  minor  degrees,  those  to  which  I  have  referred 
and  tried  to  describe,  are  usually  found  among  women.  The  intense 
heart  failure,  coming  on  rapidly,  almost  suddenly  at  times  among  men,, 
and  unquestionably  due  to  very  great  cardiac  dilatation,  against  which 
the  heart  is  almost  powerless  to  react,  is  sometimes  seen  after  great 
excesses.  These  cases,  as  we  all  know,  may  be  rapidly  or  suddenly  fatal 
despite  our  most  active  means  of  resuscitation.  Among  these  cases, 
however,  are  unquestionably  some  in  which  the  physical  signs  of  cardiac 
dilatation  are  impossible  to  determine  accurately.  I  can,  therefore,  well 
understand  that  their  existence  should  be  denied.  In  place  of  such  a 
diagnosis  I  cannot  but  substitute  one  of  loss  of  nerve-power,  either  in 
the  intracardiac  ganglia  or  in  the  trunks  of  the  vagi.     To  admit  this 


MINOR     FORMS    OF    CARDIAC     DILATATION.  87 

would  be  perhaps  also  to  acknowledge  that  the  heart  muscle  was  intact 
and  the  cavities  of  normal  dimensions.  Such  a  belief  would  be  strength- 
ened by  those  instances  in  which  certain  cardiac  tonics,  and  especially 
digitalis,  are  of  little  apparent  value,  perhaps,  indeed,  directly  injurious, 
and  rest  in  bed  and  suitable  liquid  diet  with  alcoholic  stimulants  appear 
to  be  most  useful. 

Again,  there  are  instances  in  which  there  is  certainly  no  pronounced 
structural  kidney  change,  where  we  watch  closely  the  sequence  of  clinical 
phenomena.  There  is  renal  inadequacy  only.  The  secretion  of  healthy 
urine,  viz.,  of  normal  color,  density,  in  sufficient  quantity  aud  without 
abnormal  constituents,  after  a  few  days  or  weeks  of  rest,  and  when  the 
patient  is  given  easily  assimilable  food,  returns,  and  our  temporary  fears 
are  allayed.  In  some  cases  I  recognize  a  possible  spasmodic  condition 
of  the  peripheral  vessels  and  especially  of  the  kidneys.  We  have  inti- 
mation of  this  by  high  pulse  tension  at  times  and  the  rapid  good  effects 
of  repeated  small  doses  of  nitroglycerin.  Occasionally  I  have  seen 
cases  in  which  the  heart  action  was  very  feeble,  without  any  accentua- 
tion of  the  aortic  second  sound,  and  where  the  radial  pulse  itself  had  no 
increased  tension,  and  yet  nitroglycerin  was  of  undoubted  service,  for 
after  its  use  the  heart's  action  was  notably  improved,  and  the  secretion 
of  urine,  from  being  almost  colorless  and  even  small  in  quantity  took 
on  its  normal  appearance  and  character.  No  doubt  the  nitroglycerin 
acted  as  a  direct  heart  tonic  to  the  cardiac  muscle  itself;  no  doubt,  also, 
it  dilated  the  small  vessels  of  the  kidney,  breaking  up  any  spasmodic 
condition  that  existed,  and  thus  was  of  very  great  benefit  to  the  patient. 
At  all  events,  I  have  certainly  seen  nervousness,  marked  twitching  of 
the  muscles,  apathy,  and  somnolence — all  symptoms,  as  I  believe,  indi- 
cating more  or  less  so-called  ursemic  poisoning — disappear  and  the 
patient  progressively  improve  until  fairly  good  health  and  strength 
were  established.  Examples  of  this  kind  are  not  uncommon,  I  believe 
as  a  resultant  of  what  has  appeared  to  be  a  grippal  attack. 

Through  a  contribution  to  the  London  Lancet  in  October,  1899,  by 
A.  E.  Sansom,  I  am  of  the  opinion  that  he,  also,  has  seen  cases  not  dis- 
similar. Cohnheim  and  Leyden  have  intimated  that  occasionally  the 
underlying  cause  of  ursemic  symptoms  is  found  in  cardiac  insufficiency. 
Hence  the  blood  stagnates  in  the  renal  vessels.  Clinical  observations  on 
contracted  kidneys  support  this  view,  as  does  the  use  of  cardiac  stimu- 
lants for  the  relief  of  their  manifestations. 

From  the  point  of  view  of  prognosis  the  character  of  the  pulse  is 
often  very  important.  "When  it  is  relatively  weak  and  perhaps  irregu- 
lar the  outlook  becomes  serious.  Sir  William  Broadbent  has  pointed 
out  the  gravity  of  a  pulse  of  low  tension  when  accompanied  with  symptoms 
indicating  possible  cirrhosis  of  the  kidney.  I  have  frequently  had 
occasion  to  make  a  similar  observation.     No  doubt  many  of  these  cases, 


88  MINOR    FORMS    OF    CARDIAC    DILATATION. 

however,  merely  enter  into  the  category  of  what  Sir  Andrew  Clark  has 
described  as  "  renal  inadequacy  "  accompanied  with  some  degree  of  cardiac 
dilatation.  These  are  a  class  of  cases  in  which,  although  the  kidney 
presented  no  alteration  of  structure,  it  was  unable  to  produce  a  per- 
fectly healthy  urine.  In  these  cases  the  urine  is  low  in  density  and 
deficient  in  solid  constituents,  principally  in  urea  and  its  congeners.1 

I  might  lengthen  this  paper  considerably.  I  prefer  not  to  do  so,  as  I 
very  much  desire  a  discussion  from  the  members  of  the  Association  as  to 
its  value  and  truth. 

1  Albuminuria  and  Bright's  Disease,  by  M.  Tirard,  London,  1899,  p.  16. 


CLINICAL   STUDY  OF  ACUTE  MYOCARDITIS. 


One  of  the  most  interesting  and  also  difficult  subjects  connected  with 
cardiac  pathology  is  that  of  inflammation  of  the  muscular  walls. 
Formerly,  as  we  know,  the  existence  of  this  affection  was  denied,  or,  if 
admitted  by  some  authors,  had  relatively  small  importance  as  compared 
with  inflammation  of  the  endocardium  or  pericardium.  At  a  later  date  in 
the  history  of  cardiac  disorders  myocarditis  commenced  to  assume  some 
importance.  It  is  only,  however,  within  a  brief  period  that  the  different 
affections  of  the  muscular  structure  of  the  heart  have  received  their  true 
value  and  consideration.  I  am  glad  to  state  at  present  that  the 
medical  mind  has  had  an  awakening,  and  to  those  who  are  careful 
observers  and  clinicians  the  mere  presence  of  a  murmur  or  a  pericar- 
dial friction-sound  is  no  longer  of  great  moment  unless  it  carries  with  it 
the  probability  that  sooner  or  later  real  functional  disability  will  occur 
owing  to  its  effects  upon  the  adjacent  muscular  walls.  Of  course,  the 
effects  of  muscular  changes  must  depend  largely  upon  many  conditions. 
The  causation  is  different ;  the  circumstances  in  which  they  occur  are 
manifold,  and  may  be  acute  or  chronic,  limited  or  diffuse. 

In  acute  diseases,  especially  those  affecting  the  whole  organism,  and 
mainly  those  of  febrile  type,  we  have  to  do  with  the  most  interesting 
and  most  important  cases,  because  our  time  is  limited  to  act  properly 
and  efficiently,  and  the  threatening  is  often  imminent,  although  the 
indications  may  be  obscure  and  our  useful  interference  be  questionable. 
Mere  doing  is  by  no  means  so  imperative  as  well  doing.  Life  often 
hangs  in  the  balance,  and  immediately  so. 

In  the  eruptive  fevers — in  diphtheria,  typhoid  fever,  pneumonia,  rheu- 
matism, in  many  septic  conditions,  in  toxic  states,  and,  above  all,  acute 
alcoholism  at  times — how  often  do  we  stand  at  the  bedside  and  ask,  Is 
this  a  case  where  the  muscular  fibre  of  the  heart  is  already  touched  by 
the  poison  of  the  disease  to  the  degree  where  acute  degeneration  is 
already  present?  Unquestionably  there  are  times  when  the  closest 
observation  and  attention  on  our  part  will  still  leave  us  in  great  and 
anxious  doubt.  Other  instances  present  themselves  in  which  we  feel 
that  we  are  reasonably  sure  in  our  judgment  and  are  quite  confident 
that  no  other  diagnosis  is  sufficient  or  permissible  to  explain  symp- 
toms and  signs  satisfactorily  unless  it  be  inflamed  or  degenerated 
cardiac  muscle. 

7 


90  ACUTE    MYOCARDITIS. 

In  many  instances  of  typhoid  fever  and  diphtheria  of  marked  viru- 
lence and  intensity  in  which  the  general  symptoms  have  been  alarming 
almost  from  inception  of  the  disease,  in  a  very  brief  period,  or  about 
the  fourth,  fifth,  or  sixth  days,  we  occasionally  remark  a  feeble  and 
very  rapid  heart  action.  The  first  sound  may  be  low,  distinct,  muffled  ; 
the  second  sound  may  be  somewhat  accentuated  and  particularly  over 
the  pulmonary  area,  or,  again,  this  sound,  although  still  distinct,  lacks 
force  and  normal  intensity.  With  such  a  heart  we  have  a  rapid,  feeble 
pulse,  small  in  volume,  and  easily  depressible ;  it  may  be  unequal, 
somewhat  irregular  ;  a  beat  may  now  and  then  be  lost  or  inappreciable 
to  our  tactile  sensations.  Instead  of  a  rapid  heart  we  may  have  a  slow 
one  ;  but  this  is  rare,  almost  exceptional  in  these  acute  cases.  A  soft, 
blowing  murmur  at  the  apex  and  systolic  in  time  is  often  developed. 
It  may  be  limited  as  to  its  area  or  it  may  be  widely  heard  over  the 
prsecordia.  While  this  is  true,  it  is  still  heard  most  intensely  near  the 
apex-beat  or  in  the  pulmonary  area.  In  the  latter  case  a  pulsation  of 
the  second  and  third  left  intercostal  spaces  may  accompany  it;  and 
this  pulsation  is  of  itself,  as  Russell  has  noted,  an  evidence  of  some 
degree  of  heart  failure.  Restlessness,  profuse  perspiration,  especially 
of  the  face  and  upper  limbs,  accompany  this  condition.  The  patient  is 
apathetic,  listless,  soporose,  or  frequently  there  is  a  low,  muttering  de- 
lirium from  which  he  can  be  separated  for  a  moment  only  by  acquiring 
his  attention  with  forcible  and  loud  questioning.  With  such  a  cardiac 
state  we  may  or  may  not  have  more  or  less  implication  of  the  bronchial 
tubes  or  lung  structure  ;  and  dulness  at  the  bases  with  fine  crepitation 
during  inspiration  and  over  an  area  of  at  least  a  hand's  breadth  is  no 
uncommon  finding.  The  urine  is  apt  to  be  somewhat  deficient  as  to 
quantity  and  to  contain  abundant  urates,  an  occasional  cast,  hyaline  or 
granular,  and  a  notable  amount  of  albumin. 

Cases  like  the  foregoing,  in  diphtheria  especially,  are  apt  to  terminate 
fatally  and  often  suddenly.  This  is  also  true  of  croupous  pneumonia. 
In  typhoid  fever  they  may  go  along  about  in  the  same  way  for  several 
days  and  then  perhaps  measurably  improve.  Such  cases  even  in 
typhoid  fever  are  prone  to  be  long  and  severe  ones,  and  it  is  frequently 
difficult  to  say  positively  what  the  ultimate  outcome  will  be,  even 
though  no  other  dangerous  complication  may  subsequently  arise. 

What  is  the  pathology  of  such  a  condition  ?  In  the  few  rare  in- 
stances where  I  believe  I  have  seen  it  at  the  autopsy,  very  little  at 
times  that  is  positively  indicative  of  muscular  changes.  It  is  true  the 
heart  is  soft  and  flabby ;  it  tears  more  easily  than  it  should  ;  it  is 
darker  in  color,  probably  from  blood-staining;  heart  clots  are  few, 
badly  formed,  and  usually  cruoric  in  typhoid  fever. 

In  pneumonia  and  diphtheria,  on  the  contrary,  they  are  often  in 
large  part  fibrinous,  sometimes  gelatinous-looking,  sometimes  with  the 


ACUTE    MYOCARDITIS.  91 

fluid  well  pressed  out  of  them,  and  almost  appear  to  have  several  layers 
of  superimposed  fibrin.  Extensions  of  the  clot  are  not  uncommon  in 
the  pulmonary  artery,  and  they  often  fill  moderately  the  right  ventric- 
ular cavity  and  auricle.  The  heart  may  be  somewhat  enlarged,  but 
where  this  is  the  case  I  have  attributed  it  to  previous  disease.  In  a 
similar  way  where  there  has  been  any  very  manifest  valvular  trouble 
I  could  not  believe  that  the  acute  trouble  had  anything  to  do  with  it. 

I  shall  make  an  exception  for  a  certain  degree  of  vascularization  of 
the  mitral  valve  which  I  have  seen  more  than  once.  In  diphtheria 
notably  there  is  often  a  decided  beading,  with  redness,  swelling,  and  in- 
creased vascularity  of  its  free  margin.  The  other  valves  are  usually 
normal,  at  least  to  the  naked  eye.  Under  the  microscope  the  cardiac 
fibres  present  little  or  nothing  abnormal ;  here  and  there,  perhaps,  there 
may  be  a  slight  granular  condition,  and  the  stria?  may  not  be  so  distinct 
as  normal. 

In  those  instances  in  which  I  have  seen  autopsies  later  on  in  the 
course  of  acute  disease  of  febrile  type — and  I  am  now  speaking  particu- 
larly of  typhoid  fever,  pneumonia,  and  diphtheria — I  have  occasionally 
seen  areas  of  the  heart  muscle  either  in  the  papillary  muscles  or  in  the 
walls  of  the  ventricles  which  seemed  paler  to  the  naked  eye  than  the 
rest  of  the  heart.  In  these  areas  without  doubt  there  was  a  deposit  of 
fat — microscopical  sections  have  later  revealed  decided  fatty  degenera- 
tion at  least  in  limited  areas ;  and  when  that  is  the  case  not  only  the 
nuclei  of  muscle  may  be  much  changed  in  form  and  structure,  but 
the  heart  fibres  otherwise  show  the  degeneration.  The  striation  of  some 
fibres  may  have  almost  completely  disappeared,  the  granulations  may 
be  very  numerous,  interspersed  with  many  fat  globules,  and  the  inter- 
stitial cellular  tissue  between  the  primitive  muscular  bundles  may  be 
notably  increased,  besides  containing  many  red  or  white  blood-cells. 

I  confess  there  is  no  direction  in  which  this  inflammatory  and  perhaps 
degenerative  development  interests  me  more  than  in  croupous  pneu- 
monia. The  reason  is  not  far  to  seek.  In  no  other  acute  disease  does 
life  terminate  more  frequently,  suddenly,  and  at  times  unexpectedly 
from  so-called  "  heart  failure "  than  it  does  here.  Now  what  is  this 
due  to  unless  it  be  through  the  myocardial  inflammation  or  degenera- 
tion which  has  become  developed  under  the  poison  of  the  disease?  And 
this  is  proved  particularly  when  we  encounter  those  instances  of  very 
limited  or  partial  lung  involvement,  and  yet  they  march  steadily  from 
bad  to  worse  despite  our  every  effort  made  to  save  them. 

Up  to  the  present  time  we  have  no  drug  or  system  of  medication 
that  is  in  any  way  satisfactory  to  meet  these  cases.  The  nearest  approach 
to  it,  in  my  judgment,  is  to  respond  to  the  indications  in  the  following 
manner :  on  the  one  hand,  to  help  restore  lowered  nerve  tone  and 
strengthen  muscular  activity  with  frequently  repeated  and  even  large 


92  ACUTE    MYOCARDITIS. 

doses  of  strychnine ;  and,  on  the  other,  to  destroy  or  neutralize  the 
pernicious  effects  of  bacterial  invasion  of  lung  tissue,  and  thence  the 
blood  and  whole  organism,  with  inhalations  mainly  antiseptic  in  char- 
acter, of  which  I  still  believe  beechwood  creosote  is  the  best,  though 
very  imperfect,  of  which  we  have  knowledge.  I  have  not  been  able  to 
appreciate  that  the  use  of  heart  tonics  like  digitalis  and  strophantus, 
in  anything  except  small,  repeated  doses,  and  then  only  in  a  very  tem- 
porary manner,  has  proved  to  be  really  useful.  Nor,  indeed,  with  the 
recognized  pathology  of  the  bad  cases  of  pneumonia,  diphtheria,  or 
typhoid  fever  do  I  see  how  they  could  be. 

It  always  seems  to  me  as  though  the  great  risk  of  producing  such 
forcible  contraction  of  the  relatively  healthy  fibres  as  to  effect  cardiac 
dilatation  through  distention  of  those  which  are  more  or  less  degen- 
erated neutralized  all  useful  action.  This  is  no  mere  baseless  theory. 
It  is  a  conviction  forced  upon  me  by  close,  attentive  clinical  observa- 
tion and  inquiry. 

I  believe  that  the  poisonous  effects  of  these  diseases,  certainly  so  far 
as  the  heart  is  concerned,  in  many  instances,  are  more  or  less  self- 
limited.  This  being  admitted,  our  effort  should  be  to  avoid,  above  all, 
doing  more  or  less  irretrievable  harm,  and  that,  too,  in  a  very  rapid 
manner.  In  many  of  these  cases  I  am  confident  we  do  much  less  harm 
when  we  guard  our  use  of  digitalis  and  strophanthus  with  nitroglycerin 
or  the  nitrites.  Thus  we  break  up  peripheral  resistance  as  much  as 
may  be,  and  so  we  lessen  the  necessity  of  the  heart  doing  more  work 
than  it  can  possibly  perform.  The  diffusible  stimulants  are  the  medi- 
cines which  are  most  clearly  indicated  and  many  times  urgently  re- 
quired. Alcohol,  ammonia,  ether,  chloroform,  camphor — all  these  are 
good  and  at  least  rarely  give  us  cause  for  regret. 

There  is  one  drug  which  I  feel  at  present  is  far  less  used  in  these 
acute  cases  than  it  should  be,  and  that  is  iodide  of  potassium.  Its  effect 
in  stimulating  the  nerve  centres,  especially  when  the  febrile  stage  has 
lasted  more  than  a  few  days,  is  perhaps  known  to  a  few,  but  is  not  yet 
sufficiently  insisted  upon.  Later,  of  course,  and  wherever  other  means 
have  failed  us,  and  particularly  wherever  we  dread  the  formation  of 
interstitial  growth  between  cardiac  fibres,  already  many  good  observers 
acknowledge  its  value  and  rely  upon  its  use  more  than  any  other  drug. 

With  respect  to  oxygen,  opinions  are  various.  Some  there  are  who, 
despite  frequent  use  of  oxygen,  affirm  that  it  has  little  or  no  value. 
Others  there  are  who  believe,  and  I  am  now  more  and  more  firmly  fixed 
in  this  opinion,  that  provided  we  give  oxygen  in  its  pure  form,  modified 
only  by  a  small  proportion  of  nitrous  monoxide,  freely  and  more  or  less 
continuously  during  the  stress  of  the  acute  disease,  we  shall  be  able 
frequently  to  ward  off  or  prevent  the  calamitous  effects  of  the  bacterial 
poison  in  effecting  cardiac  degeneration  and  notably  that  which  is  fatty. 


ACUTE    MYOCARDITIS.  93 

In  addition  to  the  foregoing  I  feel  called  upon  to  refer  to  the  use  of 
cold  in  pneumonia  only  to  speak  of  it  in  measured  terms  of  praise. 
While  I  have  little  doubt  that  in  some  instances  a  moderately  cold 
compress,  properly  applied  around  the  chest,  may  be  serviceable  in  re- 
lieving pain,  oppression,  and  lowering  temperature,  I  do  not  believe 
that  we  usually  obtain  the  stimulating  effects  upon  the  cutaneous  cir- 
culation and  toning  up  of  the  central  nervous  system  which  has  been 
ardently  claimed  for  it.  I  am  rather  of  the  opinion  that  similar  good 
effects  may  be  obtained  from  moderate  warmth. 

No  doubt  the  old  fashioned  poultice  of  meal  or  flaxseed  was  dirty, 
cumbersome,  and  unnecessarily  troublesome  to  the  patient  and  nurse ; 
no  doubt,  also,  by  its  frequent  change  it  fatigued  the  patient  often  very 
much,  and  yet  it  did  soothe  and  relieve.  We  shall  obtain  these  good 
effects  from  lukewarm  water  covered  with  impermeable  material,  which 
retains  heat  and  moisture  and  without  being  a  source  of  anything  like 
the  same  degree  of  annoyance. 

I  know  these  are  heterodox  views  to  many  ;  I  know  that  the  stimu- 
lating effects  of  cold  on  the  cutaneous  circulation  and  central  nervous 
system  are  most  ably  advocated  by  a  few,  and  in  this  connection  I 
should  be  derelict  not  to  mention  the  name  of  Dr.  Simon  Baruch,  who 
has  done  so  much  to  explain  and  to  fortify  those  who  hold  to  the  great 
advantages  of  cold  externally  and  internally  employed. 

I  must  confess  it  always  seems  to  me  when  a  patient's  nervous  system 
is  already  suffering  intensely  from  profound  systemic  poisoning  and 
when  degenerative  processes  are,  without  doubt,  in  a  sure  way  of  being 
developed,  that  what  we  need  especially  is  to  soothe  rather  than  to 
stimulate,  unless  with  our  stimulation  we  afford  the  food  that  is  most 
readily  disposed  of  as  fuel ;  and  such,  I  take  it,  is  essentially  the  role 
of  alcohol  and  the  ethers  in  severe  acute  febrile  disease. 

Why  is  it  when  all  other  means  fail  do  we  almost  invariably  have 
recourse  to  the  soothing  and  stimulating  effects  of  morphine  hypoder- 
matically,  or,  better  still,  sometimes  small  doses  of  extract  of  opium 
internally?  Here,  again,  I  believe  our  useful  interference  must  of 
necessity  be  a  very  measured  one.  Pass  by  the  narrow  limit,  and  we  do 
irretrievable  harm  ;  but  no  one  can  deny  when  a  heart  is  weakened  to 
its  utmost,  when  urinary  secretion  is  very  small  and  concentrated,  that 
many,  many  times  such  patients  are  marvellously  relieved  in  every  way 
by  the  use  of  these  drugs.  I  have  repeatedly  seen  the  heart  beats 
lessened  in  frequency  and  gain  in  strength  and  regularity.  I  have 
also  seen  the  urinary  secretion  become  more  abundant  and  resume  all 
its  normal  characters. 

The  question  of  the  application  of  cold,  of  course,  is  often  a  relative 
one ;  but  what  I  claim  is  that  the  application  of  a  compress  soaked  and 
wrung  from  water  at  90°  to  95°  F.  does  just  as  much  and  more  good 


94  ACUTE    MYOCARDITIS. 

than  the  compress  applied  from  water  at  65°  or  70°  F.  Very  soon 
the  compress  will  reach  the  former  or  even  a  higher  temperature  when 
the  body  is  at  103°  to  104°  F.  or  still  higher,  and  surely  the  discomfort 
and  risks  resulting  from  brief,  temporary  shocks  to  the  nervous  system 
which  frequently  repeated  cold  compresses  mean  are  not  to  be  lightly 
considered. 

As  to  the  cold  bath  in  pneumonia,  even  the  most  enthusiastic  of  the 
advocates  of  its  use  has  abandoned  it  whenever  an  adult  pneumonia 
is  treated  (see  Medical  Record,  August  4, 1900,  article  by  Simon  Baruch), 
and  finally  reserves  it  solely  for  certain  cases  of  pneumonia  in  children. 
I  am  fully  prepared  to  admit  in  this  question  of  the  utility  of  cold  ap- 
plications in  pneumonia  that  here  as  everywhere  in  the  practice  of 
medicine  allowance  must  always  be  made  for  personal  idiosyncrasy  and 
epidemic  influence.  There  are  a  few  patients  who  do  bear  cold  appli- 
cations apparently  well,  without  much  harm  resulting,  and  occasionally 
with  seeming  good  effects. 

There  are  also  seasons  in  which  pneumonias — despite  seeming  viru- 
lence, it  may  be,  at  the  start  or  in  the  initial  stage — do  not  later  show 
at  all  the  same  virulence  as  we  have  seen  at  other  times  and  under 
seemingly  like  conditions.  Why  this  is  will  not  be  satisfactorily  under- 
stood until  susceptibility  to  disease  and  the  intimate  laws  which  govern 
it  are  far  better  understood  than  they  are  by  us  today. 

It  must  be  always  borne  in  mind  in  the  care  of  these  cases  how  essen- 
tial it  is  to  prevent  as  far  as  possible  all  exertion  on  the  part  of  the 
patient.  The  nurse  should  see  to  it  that  whenever  a  change  of  position 
is  desirable  she  should  aid  him  as  far  as  she  can  ;  even  the  raising  of 
the  head  in  the  voluntary  act  of  drinking  should  be  assisted.  An 
alarming  or  fatal  attack  of  syncope  may  possibly  occur  unless  attention 
be  thus  rigidly  exercised.  Frequently  repeated  and  easily  assimilable 
nutrition  should  be  kept  up  with  beef  peptonoids,  milk,  koumyss,  broths, 
egg-nog,  etc. 

In  more  than  one  instance  I  have  felt  assured  that  I  have  helped  my 
patient's  condition  markedly  by  giving  an  ounce  or  more  of  black  coffee 
by  the  mouth  several  times  in  twenty-four,  hours,  or  a  stimulating 
enema  of  coffee  per  rectum  in  much  larger  quantity  if  there  was  evident 
great  prostration,  sudden  collapse,  or  pronounced  stomachal  intolerance. 

Later  on  in  the  course  of  acute  febrile  diseases  sudden  death  from 
heart  failure  due  to  myocarditis  is  not  very  infrequent.  I  have  known 
it  to  occur  in  diphtheria  when  the  outlook  had  appeared  relatively 
favorable  and  when  the  convalescent  stage  was  almost  reached.  I 
have  also  had  at  least  one  sad  experience  of  it  with  a  child  recovering 
apparently  from  typhoid  fever.  In  many  instances  I  have  had  little  or 
no  doubt  that  owing  to  acute  degeneration  of  cardiac  muscular  fibres 
death  occurred  which  might  otherwise  have  been  averted. 


ACUTE    MYOCARDITIS.  95 

In  these  cases  there  have  been  areas  of  the  papillary  muscles  or  of 
the  left  or  right  ventricular  walls  where  the  yellow  coloration,  soft, 
friable  tissue  and  perhaps  greasy  feel  gave  to  the  naked  eye  positive 
indications  of  what  the  microscope  would  surely  reveal,  viz.,  more  or 
less  complete  disappearance  and  fatty  degeneration  of  muscular  fibres. 

It  is  reported  by  several  reliable  observers  that  they  have  found  also 
hyperplasia  of  connective  tissue  between  the  fibres,  with  numerous  leu- 
cocytes, red  cells,  and  proliferative  cells.  Pigment  granules,  regularly 
or  irregularly  disseminated  within  and  between  muscular  fibres,  have 
been  frequently  observed.  This  change,  especially  as  regards  quantity, 
is  more  apt  to  occur  the  older  the  patient  is.  The  cells,  both  of  muscle 
fibre  and  cellular  tissue,  are  much  changed  in  form  and  structure  or 
may  have  disappeared  altogether.  It  is  also  true  that  horizontal  stria- 
tum of  muscle  and  the  long  fibrillation  often  no  longer  exist  in  parts. 
The  muscular  fibre  maybe  almost  hyaline  in  appearance  and  relatively 
broad.  It  may  be  also  atrophied  and  diminished  in  size  owing  to  the 
pressure  and  contraction  exerted  by  connective  tissue  increase.  The 
latter  change,  however,  is  one  much  more  frequently  met  with  in 
chronic  myocarditis,  where  almost  all  changes,  according  to  some  writers, 
partake  of  this  character  and  make  a  real  fibroid  degeneration  of  the 
cardiac  muscle. 

We  should  not  expect  to  find  fatty  changes  always  widely  dissem- 
inated or  deeply  seated.  Frequently  these  changes  are  merely  in 
patches,  and  elsewhere  the  cardiac  fibre  is  apparently  and  relatively 
healthy  so  far  as  the  microscope  reports.  Even  in  the  midst  of  a  local 
degeneration  of  tissue  certain  fibres  are  much  more  affected  than  others, 
and  alongside  of  one  fibre  which  is  almost  wholly  granular  or  fatty 
another  will  be  found  nearly  intact. 

In  those  cases  where  there  is  accompanying  endocarditis  or  pericar- 
ditis the  degeneration  is  apt  to  be  much  more  diffuse  than  where  no  in- 
flammatory condition  of  these  membranes  exists.  The  papillary  muscles 
and  the  ventricles,  especially  the  left  near  the  apex,  are  the  parts  usually 
most  degenerated.     The  auricles  are  very  rarely  at  all  notably  involved. 

In  many  of  these  cases,  although  the  symptoms  and  signs  during  life 
pointed  with  great  certainty  toward  probable  degeneration  of  muscular 
cardiac  fibre,  we  are  surprised  at  the  autopsy  to  find  little  or  no  evidence 
of  it.  Beside,  the  valves  and  orifices  are  usually  intact ;  at  least  there 
is  no  evidence  of  acute  inflammation  or  old  sclerotic  changes.  The 
heart,  however,  is  soft,  flabby,  has  lost  its  shape,  flattens  out  when  rest- 
ing on  the  table ;  the  walls  are  sometimes  somewhat  thinner  than  normal 
and  the  cavities  slightly  increased  in  size.  In  such  cases  when  the  right 
or  left  ventricle  is  opened  at  the  apex  and  the  hydrostatic  test  made  the 
valve  is  not  competent. 

Two  facts  are  thus  explained  to  my  mind  which  have  been  recognized 


96  ACUTE    MYOCARDITIS. 

during  life  :  first,  functional  disability  ;  second,  a  soft,  blowing  murmur, 
heard  at  the  apex  during  systole.  All  we  can  positively  say  of  such 
hearts  is  that  they  are  really  weakened  by  disease — that  they  have  lost 
their  contractile  power.  Such  hearts  may  have  been  primarily  weak 
organs,  and  just  as  they  might  not  have  been  able  to  react  properly  to 
any  undue  or  excessive  strain  during  health  without  showing  the  bad 
effects  of  it,  so  during  an  attack  of  acute  febrile  disease  they  give  way 
rapidly  both  in  function  and  structure. 

Of  course,  to  the  pure  anatomist  or  pathologist,  who  regards  only 
organic  lesion  as  shown  by  eye  and  microscopical  lens,  to  speak  of  func- 
tional adynamia  as  something  all  important  smacks  too  closely  of  mere 
vague  theory  without  proper  and  sufficient  basis  for  intelligent  argu- 
ment;  but  to  others,  and  among  these  I  find  myself,  there  is  just  as 
much  cogency  in  the  reasoning  which  admits  a  latent  force  or  energy — 
a  vitality,  in  other  words,  which  exists  to  a  greater  or  less  degree  in 
certain  tissues  of  individuals  and  which  is  very  defective  in  others — as 
to  attribute  all  symptoms  and  signs  to  appreciable  local  changes. 

In  any  event,  and  for  the  while,  we  must  count  with  such  reasoning 
and  such  facts  ;  and  it  is  not  the  evidence  of  highest  wisdom,  to  my  mind 
to  ignore  them.  We  are  prone  to  explain  these  facts  occasionally  when 
our  every  effort  at  accurate  research,  both  as  regards  the  tissues  and 
fluids  of  the  economy,  remains  negative,  by  speaking  of  being  run  down, 
under  par,  of  poor  nutrition,  and  using  such  catch  terms  as  though 
these  words  or  expressions  advanced  our  knowledge  very  materially  or 
were  satisfactory  in  any  final  discussion. 

In  the  malade  imaginaire  of  Moliere  there  is  a  conference  of  the  learned 
doctors  as  to  how  and  why  opium  causes  sleep.  The  final  conclusion 
reached  was  "opium  a  le  pouvoir  dormitif"  and  that  is  all  there  is  to  it. 

All  saving  agents,  so  to  speak,  whether  regarded  as  food  or  medicines, 
seem  to  me  rationally  what  we  should  most  keenly  look  for  when  called 
upon  to  treat  these  cases.  This  is  why  agents  such  as  tea,  coffee,  cocoa, 
kola,  etc.,  are  so  valuable  when  the  body  is  submitted  to  a  great  strain 
and  where  little  or  no  other  food  or  drink  can  be  had.  Take  the  sol- 
diers of  our  army,  the  sailors  of  our  navy,  in  time  of  war,  on  forced 
marches  or  imprisoned  in  fortresses ;  take  men  on  the  plains,  or  ex- 
plorers iu  the  Arctic  regions,  or  mountaineers  who  make  high  and 
laborious  ascensions — in  any  and  all  of  these  situations  the  universal 
report  is  that  in  time  of  greatest  need  nothing  will  or  can  replace  them. 
Not  only  do  they  seemingly  give  almost  as  much  if  not  more,  at  times, 
of  temporary  energy  and  strength  than  alcohols  or  ethers,  but  their 
power  is  far  more  enduring  and  beneficial  when  exposure  or  hardship 
has  to  be  for  a  long  time  resisted. 

Physiologically  they  lessen  the  rapidity  and  degree  of  combustion  in 
the  economy,  the  tissues  are  thus  saved  from    any  destructive   action  of 


ACUTE     MYOCARDITIS.  97 

phagocytic  cells,  and  living  force  and  energy  are  thus  spared  to  their 
utmost 

I  have  attempted  in  giving  black  coffee  frequently  to  my  cases  of 
acute  febrile  disease,  with  evidences  of  heart  weakness  or  cardiac  degen- 
eration, to  meet  the  most  evident  indications  up  to  the  present  time.  I 
have  supplemented  or  varied  the  use  of  coffee  at  times  both  with  cocoa 
and  kola.  The  former  of  these,  particularly  in  the  form  of  extract, 
given  by  mouth  or  hypodermatically,  has  often  helped  me  when  I  had 
almost  given  up  hope.  I  am  inclined  to  believe  that  if  my  faith  and 
trust  were  greater,  and  I  were  to  use  these  agents  sooner  and  more  freely, 
I  would  get  far  better  results  in  cases  of  acute  myocardial  degenera- 
tion. One  reason  I  believe  that  these  agents  do  not  always  respond  to 
our  hopes  is  because  the  preparation  employed  is  relatively  inert.  Many 
cocoa  leaves,  as  many  digitalis  leaves,  are  dry  and  inert  and  of  poor 
quality  when  first  gathered.  I  cannot  place  too  much  insistence  upon 
this.  I  have  experimented  with  many  preparations  of  cocoa  as  sold  by 
different  druggists,  and  many  are  relatively  inactive  and  worthless. 
Too  much  care  and  inquiry  cannot  be  taken  in  order  to  obtain  a  thor- 
oughly reliable  drug.  And  it  is  only  too  true  that  the  power  the  best 
of  us  have  over  the  march,  duration,  and  ultimate  outcome  of  acute 
disease  is  limited,  and  that  this  small  power  is  reduced  to  a  minimum 
when  we  employ  drugs  which  have  little  or  no  physiological  action 
when  employed  in  the  doses  and  forms  which  are  wide-spread. 

Hence,  in  part,  the  great  skepticism  so  visible  everywhere  among  our 
best  clinicians  and  practitioners  of  widest  experience  when  they  speak 
of  the  curative  action  of  drugs.  There  are,  I  freely  admit,  few  truly 
valuable  ones  among  the  vast  mass  of  those  that  are  advertised  and  sold, 
and  for  this  reason,  also,  it  behooves  us  jealously  to  guard  and  protect 
those  that  are  from  the  meddling  of  ignorant,  fraudulent  persons. 

In  many  cases  of  acute  myocarditis  the  question  arises  as  to  whether 
we  have  to  do  with  concomitant  endocarditis  or  pericarditis.  In  some 
cases,  indeed,  it  is  undetermined  for  a  time  at  least  as  to  whether  the 
symptoms  and  signs  present  are  not  entirely  due  to  the  inflammation 
of  the  endocardium  or  pericardium  and  the  myocardium  is  little  or 
not  at  all  involved  in  inflammatory  or  degenerative  changes. 

Endocarditis  is  not  easily  diagnosed  at  times ;  it  may  be  very 
obscure.  The  local  symptoms  are  often  almost  or  entirely  absent,  with 
the  exception  of  the  systolic  murmur  present  over  a  limited  or  some- 
what wide  area  of  the  prsecordia.  There  may  be  no  localized  pain  or 
marked  discomfort ;  no  increased  pulse  or  force  in  cardiac  beats;  no 
irregularity  or  intermittency  of  cardiac  contractions  ;  no  abnormal  pul- 
sation in  intercostal  spaces ;  no  vascular  distention  in  vessels  of  the 
neck.  The  local  expression  of  endocardial  inflammation  in  slight  de- 
gree simply  reduces  itself  to  the  murmur.     It  is  true  this  murmur  may 


98  ACUTE    MYOCARDITIS. 

be  rougher,  more  intense,  more  metallic  than  the  one  proceeding  from 
mere  dilatation  of  orifice  without  local  change  or  from  lack  of  close 
coaptation  of  the  velse  due  to  lack  of  power  in  the  heart  muscle ;  but, 
as  we  know,  the  nature  and  intensity  of  a  bruit  is  not  of  itself  absolutely- 
characteristic  of  inflammatory  or  other  changes.  Again,  and  this  is 
more  frequently  true,  the  murmur  itself  is  absolutely  similar  to  one  that 
we  may  fairly  attribute  to  myocarditis  alone.  The  pulse,  of  course,  in 
endocarditis  may  rapidly  gain  appreciably  in  force  and  frequency,  but 
this  is  usually  true  only  when  the  inflammation  of  the  endocardium  is 
considerable.  There  may  be  a  sudden  or  rapid  rise  of  temperature ;  but 
here,  again,  this  means  marked  inflammatory  changes  of  the  endocar- 
dium, and  if  accompanied  by  rigors  or  repeated  chilly  sensations  there 
will  arise  a  reasonable  suspicion  as  to  whether  there  is  not  some  septic 
process  present,  such,  indeed,  as  would  lead  to  the  ulcerative  form  of 
endocarditis.  If  this  be  true  usually  the  murmur  has  shown  itself 
rapidly  and  with  much  intensity,  and  its  loudness  very  soon  increases, 
beside  being  accompanied  with  general  phenomena  quite  different  from 
those  of  myocarditis,  with  tendency  to  cardiac  weakness  or  failure. 

I  admit  that  much  of  the  differential  diagnosis  is  based  upon  proba- 
bilities rather  than  upon  certainties ;  but  this  statement  is  no  truer  and 
need  be  no  more  emphatic  than  in  numerous  other  difficult  positions  in 
the  practice  of  medicine.  Of  course,  the  presence  of  a  special  form  of 
disease  must  always  be  considered.  Other  conditions  being  the  same 
I  should  look  for  endocarditis  as  being  far  more  probable  in  acute 
rheumatism  than  the  other  diseases  already  mentioned,  simply  because 
we  know  that  acute  rheumatism  has  a  particular  predilection  to  attack 
the  endocardium.  Even  in  rheumatic  fever,  however,  I  am  now  con- 
vinced that  we  have  rather  exaggerated  this  tendency  at  times,  and  that 
many  instances  of  what  is  commonly  affirmed  to  be  endocarditis  have 
been  without  doubt  mainly  a  myocardial  inflammation  or  degeneration. 

While  I  have  not  always  been  able  to  make  the  differential  diagnosis 
in  the  initial  stage  of  the  manifest  cardiac  determination,  the  march 
of  the  disease  and  the  nature  and  perhaps  rapid  or  sure,  though  slower, 
disappearance  of  the  cardiac  abnormal  bruit  have  thoroughly  convinced 
me  of  the  physical  cause  producing  it. 

If  there  be  a  pericardial  inflammation  the  superficial  character  and 
the  nature  of  the  friction-sounds  may  be  sufficient  to  differentiate  these 
cases.  Moreover,  very  soon  the  increased  and  special  form  of  cardiac 
dulness,  the  particular  displacement  of  the  apex-beat,  the  distant  and 
more  muffled  and  duller  apex- beats,  with  very  possibly  the  almost  entire 
absence  of  these  beats  to  inspection,  and  it  may  be  palpation,  help  the 
accuracy  of  our  differential  diagnosis  very  much. 

I  have  not  had  occasion  to  see  hearts  at  the  autopsy  table  in  cases  of 
influenza  except  where  this  disease  had  been  complicated  with  pneu- 


ACUTE    MYOCARDITIS.  99 

monia,  and  then  the  hearts  resemble  somewhat  those  already  described. 
One  marked  difference,  however,  is  in  the  contents  of  the  cavities.  In- 
stead of  the  right  ventricle  and  auricle  and  large  vessels  containing 
fibrinous  coagula,  these  were  much  softer,  contained  far  less  fibrin,  and 
were  darker  and  far  more  cruoric,  viz.,  contained  a  far  larger  number 
of  red  blood-globules.  I  am  quite  confident,  however,  that  the  heart 
of  very  many  influenza  patients  is  much  affected.  I  have  no  doubt 
that  the  nervous  structures,  ganglia,  vagi,  and  sympathetic  have  lost 
their  tone  and  gone  through  certain  changes.  They  may  be  recognizable 
under  the  microscope  on  account  of  the  cardiac  and  other  symptoms 
present  during  life. 

Beside  the  nervous  involvement  there  is  also  abundant  evidence  in 
influenza  that  the  muscle  is  attacked,  and  it  is  highly  probable  that  the 
great  depression,  continued  weakness,  syncopal  attacks,  slow  recovery, 
frequent  returns  of  some  of  these  symptoms  subsequently  and  somewhat 
periodically  at  times,  are  all  due  in  part  to  myocardial  changes.  In  no 
disease  with  which  I  have  a  clinical  experience  is  it  more  important  to 
guard  patients  against  overexertion  than  influenza  during  its  acute 
and  subsequent  stages. 

Patients  who  have  been  attacked  severely  with  this  disease  may  show 
after  a  few  weeks  or  months  some  cardiac  enlargement  due  to  dilatation 
and  evidently  occasioned  directly  by  the  influenza  attack.  Not  only, 
therefore,  during  the  period  of  the  acute  stage  of  this  disease  should  we 
be  specially  careful  in  not  permitting  any  physical  exertion — not  even 
the  mere  sitting  posture  in  bed  without  assistance  and  support — but 
we  should  for  many  weeks  subsequent  to  an  attack  at  all  severe  urge 
upon  patient  and  friends  the  absolute  necessity  of  great  prudence  and 
the  strict  avoidance  of  all  intemperate  or  continuous  bodily  or  mental 
effort.  Many  hours  of  the  twenty-four  had  better  be  passed  in  repose 
or  sleep  and  complete  quiet  mentally,  and  the  recumbent  posture 
should  be  sought  whenever  the  heart  shows  any  signs  of  exhaustion. 
Going  up  stairs,  walking  too  rapidly,  lifting  heavy  burdens,  indulgence 
at  the  table,  use  of  tea,  coffee,  or  tobacco,  should  all  be  strictly  limited 
for  many  weeks  or  months.  Of  course,  there  is  the  personal  equation 
here,  as  everywhere  in  medicine,  and  there  are  many  patients  who  re- 
cuperate rapidly  even  from  an  attack  of  influenza,  and  who  on  that 
account  need  not,  perhaps,  exercise  quite  the  same  severe  precautionary 
measures  as  others.  It  is  also  true  that  the  poison  may  be  far  less 
virulent  in  certain  instances  than  in  others,  and,  therefore,  we  should 
not  expect  the  same  severe  effects  to  proceed  from  it.  Nevertheless,  it 
is  ever  a  safe  rule  to  bear  in  mind  how  essential  it  is  for  the  patient's 
ultimate  well-being  to  be  careful  in  the  convalescent  period  of  in- 
fluenza, typhoid  fever,  rheumatism,  diphtheria,  the  eruptive  fevers,  and 
pneumonia. 


100  ACUTE    MYOCARDITIS. 

I  have  seen  many  times  in  the  convalescent  stage  of  these  diseases 
the  pulse  remain  unduly  frequent  for  long  periods  of  time,  and  I  have 
likewise  seen  this  tachycardia  show  itself  after  very  slight  exertion, 
when  the  patient  otherwise  seemed  well  and  could  scarcely  be  made  to 
appreciate  the  importance  of  considering  this  symptom,  which  pointed 
clearly  to  weakness  of  the  muscular  walls  of  the  heart. 

Bradycardia  may  also  be  present,  and  the  marked  slowness  of  the 
pulse,  going  down  frequently  to  fifty  pulsations  or  less,  may  be  the 
most  important  if  not  almost  the  sole  evidence  of  impairment  of  cardiac 
power.  Surely  too  much  emphasis  cannot  be  placed  on  the  judicious 
valuation  of  this  condition.  If  it  be  properly  considered  and  wisely 
treated  not  only  will  convalescence  be  in  the  end  much  shortened,  but 
all  danger  of  subsequent  probability  of  cardiac  dilatation  will  be  avoided 
as  far  as  may  be. 

It  is  manifest  that  in  cases  of  moderate  endocarditis  or  pericarditis, 
during  their  acute  stage  especially,  it  is  incumbent  upon  us  to  insist 
upon  absolute  rest  in  bed  in  the  recumbent  posture  (and  even  though 
the  type  of  dise'ase  in  which  it  occurs  may  be  very  mild  in  char- 
acter) for  many  days  or  even  weeks  ;  and  yet,  after  all,  I  do  not  believe 
the  danger  from  overexertion  in  these  affections  is  half  so  great  when 
they  are  unaccompanied  with  myocardial  changes,  nor  do  I  believe 
that,  per  se,  they  are  so  threatening  to  the  future  well-being  of  the 
patient. 

I  do  not  deny  that  the  facts  to  which  I  have  referred  are  more  or 
less  well  known  to  the  average  good  clinician  and  wise  practitioner ; 
still,  I  know  in  my  own  case  it  has  taken  many  long  years  of  practical 
observation  and  experience,  and  the  care  of  numerous  patients,  to  thor- 
oughly convince  me  of  its  very  great  interest  and  importance.  Here  is 
where,  unfortunately,  the  modern  text-book  of  practice  falls  far  short  of 
actual  needs.  Sayings  similar  in  import  to  mine  may  be  alluded  to  in 
a  line  or  two,  but  that  is  about  all,  and  unless  a  man's  own  thought  and 
daily  experience  and  observation  serve  to  bring  the  facts  constantly 
before  him  he  is  prone  to  ignore  or  forget  them.  Even  modern  text- 
books on  cardiac  disorders  are  apt  to  be  far  too  brief,  in  my  judgment, 
in  treating  of  the  importance  of  rest  in  the  treatment  of  acute  disease. 

Most  people  will  swallow  drugs,  cover  themselves  with  lotions  and 
liniments,  be  blistered  or  burnt,  even  go  through  a  minor  surgical  oper- 
ation, with  far  more  equanimity  and  resignation  than  they  will  submit 
to  being  put  to  bed  and  remain  there  for  days  or  weeks  unless  they  are 
in  great  pain  or  are  suffering  from  some  marked  disablement  that  they 
can  thoroughly  appreciate.  The  practitioner  has  a  difficult  role  many 
times,  especially  during  the  convalescent  period,  in  managing  these 
patients  to  their  own  advantage. 

It  is  not  always  wisdom  to  explain  to  people   about    their   ailments. 


ACUTE     MYOCARDITIS.  101 

They  try  to  understand    the   doctor's   position,    and  yet  they  do  not. 
They  either  exaggerate  the  gravity  of  their  own  case  or  ignore  it  far 
too  much.     Whenever  it  is  a  question  particularly  of  the  heart,  infinitely 
more  harm  is  sometimes  done  by  showing  accurately  by  explanation  in 
what  the  danger  consists  than  in   part   to   avoid  explanation,  or  not  to 
speak  at  all,  except  to  avoid  making  any  categorical  statement.     This  is, 
of  course,  deplorable  for  many  reasons.     Truth  is  mighty  and  should 
prevail,  and  an  intelligent  man  or  woman  should  claim  the  right  to  know 
precisely  what  the  matter  is   and  what  the  physician   really  thinks  of 
their  case.     Just  as  soon,  however,  as  the  bald  statement  is  made  that 
the  heart  structure  is  at   all    affected,  then    they  proceed    by  vain  im- 
aginings to  make  themselves  miserable  for  a  long,  long  while  to   come. 
It  becomes  almost  impossible  at  times  to  disabuse  their  minds  and  make 
life  tolerable  to  them.     They  fret  and  worry,  become  introspective  and 
hypochondriacal,  and  lose  snap  and  energy,  which  render  their  lives  a 
burden  to  themselves  as  well  as  to  others.     They  are  often  the  victims 
of  false  dreads  and  foolish   fears ;  they   imagine    they  cannot  recover 
and  must  always  be,  to  a  certain   extent,  invalids ;  they  harp  on  their 
hearts,  and   they  run   from  one  physician    to  another  to  obtain  expert 
judgment.     It  would  seem  as  though  the  minds  of  such  could  be  dis- 
abused, and  that  the   earnest,  convinced   statement   of  their   physician 
that  they  would  get  all  right  in  time  if  they  are  only  careful  and  sen- 
sible would  be  sufficient  to  quiet  their  fears  and  restore  healthy  mental 
fibre ;  but,  alas  !  in  many  cases  this  unhappily  is  not  true. 

I  do  not  wish  to  be  understood  as  upholding  at  all  that  this  should 
make  the  practitioner  either  untruthful  or  misleading,  but  I  do  mean 
to  say  that  it  should  make  him  very,  very  careful  and  circumspect  as 
to  what  he  says.  He  must  wholly  gauge  the  disease  he  has  to  treat ; 
he  must,  also,  always  consider  the  personality  he  has  to  do  with  ;  and 
singular  it  is  that  the  very  persons  whom  we  might  suppose  are  those 
least  likely  to  be  demoralized  by  the  truth  if  spoken  fully  and  without 
prevarication  are,  perhaps  of  all  others,  the  ones  to  become  most  readily 
discouraged  and  ultimately  the  most  miserable  unless  with  much 
time,  tact,  and  care  they  are  absolutely  convinced  of  the  error  in  their 
thoughts. 

With  respect  to  the  other  treatment  of  endocarditis  or  pericarditis,  if 
they  be  present,  I  would  add  that  while  I  believe  counter-irritation  in 
the  form  of  iodine  or  blisters  very  useful  frequently  in  shortening  their 
duration  and  intensity,  I  am  not  convinced  that  they  would  have  much 
value  in  the  treatment  of  independent  myocarditis  of  the  sort  I  have 
endeavored  to  study. 

As  to  warm  applications  over  the  prsecordia,  and,  better  still,  hot 
fomentations  frequently  repeated,  and  particularly  where  there  is  evident 
cardiac  weakness,  these  I  believe  are  of  really  great  value.     They  cer- 


102  ACUTE    MYOCARDITIS. 

tainly  stimulate  cardiac  contractions  to  a  very  notable  degree,  and  even 
though  there  be  considerable  increase  already  in  bodily  temperature,  I 
recognize  no  strong  objection  to  their  use. 

To  my  mind,  the  question  of  the  amount  of  fever  is  often  of  secondary 
importance,  and  in  nearly  all  cases  is  but  one  of  numerous  symptoms 
pointing  to  the  intensity  or  gravity  of  the  systemic  poisoning.  To  com- 
bat it  rationally  and  without  manifest  detriment  to  other  expressions  of 
disease  may  be  all  right,  indeed  probably  is  correct  according  to  our 
actual  knowledge.  To  do  more  than  this  is  many  times  obviously 
uncalled  for,  and  tends  very  much  to  produce  harmful  interference. 

If  the  condition  be  already  an  adynamic  one,  where  the  bodily  forces 
are  at  a  very  low  ebb  and  other  forms  of  immediate  and  powerful 
stimulation  are  required,  I  fail  to  see  why  transmitted  heat,  properly 
applied,  may  not  awaken  and  indeed  partially  restore  wasted  nerve  force 
very  much  more  certainly  than  cold.  To  cite  particular  instances  in 
which  this  is  true,  even  though  not  wholly  analogous,  would  not  be 
difficult. 

In  any  great  shock  to  the  nervous  system  following  a  blow  or  fall ;  in 
the  complete  nervous  depression  from  loss  of  blood  ;  in  the  nervous 
exhaustion  caused  by  fright  or  imminent  peril ;  in  the  utter  goneness 
accompanying  bodily  privations  due  to  lack  of  food  or  sleep,  heat 
locally  applied  over  the  heart,  either  as  hot-water  bag,  hot  compresses, 
mustard  poultices  (where  it  is  combined  with  the  counter-irritant), 
would  be  our  first  thought  and  usually  prove  most  helpful ;  and  as  the 
body  heat  of  an  infective  disease  is  in  many  particulars  nothing  very 
different  from  the  other  appreciable  expressions  of  lowered  nerve  tone, 
why  not  make  use  of  it  promptly  and  efficiently  ?  ■ 

As  to  the  general  treatment  of  endocarditis  and  pericarditis,  I  would 
naturally  incline  to  the  use  of  the  salicylates  in  moderate  doses  if  acute 
rheumatism  were  present ;  but  I  should  be  more  than  doubtful  of  their 
utility  even  in  these  instances  where  there  were  complications  of  the 
other  febrile  conditions  studied  in  this  article.  Certainly,  I  would  not 
give  them  where  the  nutrition  was  already  at  a  low  ebb  or  the  stomach 
had  shown  signs  of  intolerance. 

During  the  convalescent  period  of  acute  myocarditis  complicating 
acute  febrile  diseases  the  indications  for  massage,  resistant  movements, 
and  saline  carbonic  baths,  according  to  the  Schott  system  employed 
originally  at  Nauheim,  seem  pretty  clearly  defined. 

It  is  to  be  borne  in  mind,  however,  that  just  as  dyspnoea  is  often  a 
very  marked  symptom  of  myocarditis  in  its  most  acute  stage,  so  later  it 
will  frequently  guide  and  direct  us  as  to  the  efficacy  of  the  move- 
ments and  baths  and  the  duration  of  them.  On  its  appearance  in  any 
notable  degree  they  should  be  stopped  and  only  resumed  with  great 
care  and  moderation.     Harm  results  more  frequently  from  doing  too 


ACUTE    MYOCARDITIS.  103 

much  at  too  early  a  period  than  through  a  judicious  reserve  as  to  both 
of  these  considerations. 

It  is  true  that  the  Nauheim  treatment  employed  at  the  spring?,  or 
artifically  used  elsewhere,  may  prove  to  be  very  beneficial  in  well- 
selected  cases,  even  though  the  heart  fibres  be  degenerated.  It  is, 
also,  unquestionable  that  where  the  degeneration  is  far  advanced  and 
the  general  nutrition  has  become  much  undermined  by  previous  disease 
or  advancing  years,  it  may  work  more  than  passing  harm  and  become 
of  very  little  real  value,  but  rather  detrimental  than  the  reverse. 

Acute  myocarditis  may  and  does  occur  frequently  among  children 
as  a  complication  of  their  acute  febrile  diseases,  and  especially  is 
this  to  be  remembered  in  scarlatina,  whooping-cough,  diphtheria,  and 
measles. 

I  am  confident  that  this  acute  degeneration  of  heart  muscle  will 
many  times  explain  sudden  failure  of  cardiac  power  when  apparently 
the  patient  is  progressing  favorably.  I  am  also  convinced  that  it 
will  explain  the  delayed  convalescence  of  numerous  cases  in  which  this 
complication  would  easily  be  disregarded  or  overlooked  unless  partic- 
ular attention  be  directed  to  it.  No  doubt  many  instances  of  subse- 
quent cardiac  dilatation,  with  or  without  accompanying  hypertrophy, 
have  been  occasioned  solely  by  inattention  to  or  ignorance  of  this 
muscular  degeneration. 

The  very  activity  of  children,  their  desire  to  play  and  romp  and  tire 
themselves  with  their  games  and  contests,  is  an  additional  reason  why 
special  care  should  be  exercised  so  as  to  ward  off  an  unfortunate  sequela 
which  may  be  otherwise  lasting  and  troublesome.  I  have  not  infre- 
quently met  with  cases  which,  as  I  interpret  them  at  present,  may  trace 
their  later  cardiac  inadequacy  to  the  influence  of  diseases  of  early 
childhood. 

I  do  not  believe,  in  my  experience,  that  the  acute  myocarditis  of  chil- 
dren differs  very  materially,  so  far  as  symptoms  go,  from  the  same  dis- 
ease in  adults.  The  ultimate  prognosis,  however,  it  seems  to  me,  is  less 
serious,  simply  because  the  nutrition  of  the  child  being  usually  more 
active  his  cell  elements  are  re-established  sooner  and  more  surely,  and 
hence  the  untoward,  far-reaching  effects  of  cardiac  weakness  are  less 
likely  to  become  manifest. 


CHRONIC   MYOCARDITIS  AND  FATTY  DEGENERA- 
TION OF  THE  HEART. 


OLiNicALLy  these  two  expressions  of  cardiac  degeneration  are  fre- 
quently most  difficult  to  differentiate  accurately.  We  have  our  sus- 
picions based  upon  a  fair  interpretation  of  the  case  as  a  whole,  and 
sometimes  the  results  of  the  autopsy  justify  our  probable  diagnosis. 
Many  times  we  believe  we  shall  find  not  merely  fibroid  changes  or, 
indeed,  simple  fatty  degeneration,  but  there  will  be  a  combination  of 
both  changes.  In  the  advanced  forms  of  fatty  change  particularly, 
and  whenever  we  have  in  the  history  of  the  patient  efficient  causation 
of  such  alteration,  our  belief  in  its  existence  is  very  positive.  There 
are,  however,  numerous  instances  in  which  our  diagnosis  during  life  is 
at  best  very  problematical,  and  yet  it  seems  to  me  any  other  diagnosis 
at  what  we  observe  falls  short  of  seeming  truth,  and  is  at  best  somewhat 
unsatisfactory  to  the  practitioner.  While  we  know,  for  example,  in 
the  graver  forms  of  ansemia,  and  notably  in  the  so-called  pernicious 
form,  fatty  degeneration  of  heart  muscle  is  no  uncommon  finding,  I  do 
not  believe  that  physicians  are  apt  to  consider  that  the  heart  may  be 
structurally  affected  in  the  simpler  forms. 

It  is  true  that  many  symptoms  point  to  cardiac  weakness.  Notably 
we  would  put  emphasis  on  lowness  of  the  heart  sounds  at  times,  on 
extreme  rapidity  of  its  beats,  with  sensations  of  fluttering  and  cardiac 
distress.  Sometimes  there  is  a  systolic  murmur  which  covers  in  part 
or  wholly  the  normal  sound.  Frequently  this  is  absent.  Attacks  of 
dizziness  or  faintness  may  come  on  readily  and  repeat  themselves  with 
little  or  no  sufficient  cause.  I  have  seen  such  an  attack  where  the 
patient  was  unconscious  for  a  period  of  half  an  hour  or  more.  During 
this  period  the  pulse  was  very  faint,  sometimes  almost  imperceptible  at 
the  wrist.  There  was  occasionally  a  lapse  of  pulsations  at  the  wrist 
for  one  or  two  cardiac  beats,  accompanied  with  marked  irregularity. 
The  extremities  were  cold,  the  respiration  shallow  and  suspicious. 
After  such  attacks  and  when  the  patient's  strength  had  partially 
returned  there  was  no  enlargement  of  the  heart  which  could  be  discov- 
ered, no  abnormal  pulsations  either  on  the  chest  or  in  the  neck,  and 
no  venous  hum  in  the  jugulars. 


CHRONIC    MYOCARDITIS.  105 

I  am  of  the  opinion  to-day  that  such  cases  often  mean  heginning 
cardiac  degeneration  of  the  fatty  type,  and  that  any  other  interpreta- 
tion inadequately  expresses  the  best  medical  judgment.  Of  course,  they 
require  iron  and  arsenic  to  re-establish  the  blood  condition.  They  are 
also  temporarily  benefited  at  times  by  the  use  of  intestinal  antiseptics; 
still,  in  order  to  bridge  over  the  acute  attacks  we  must  give  cardiac 
stimulants  freely  and  repeatedly  and  aid  with  the  heart  tonics  of 
strophanthus  and  strychnine  judiciously  administered.  Oxygen  also 
given  systematically  is  of  great  help  and  must  be  insisted  upon. 

We  all  feel  we  know  the  usual  gouty  heart  fairly  well,  viz.,  the  heart 
affected  with  moderate  hypertrophy  of  the  left  ventricle  and  adjoined 
to  evidences  of  more  or  less  fibroid  changes  in  the  kidney  and  general 
arterio-capillary  circulation.  Whenever  this  hypertrophy  is  no  longer 
thoroughly  compensatory  and  evidences  of  heart  weakness  develop,  as 
shown  by  local  and  general  signs  and  symptoms,  we  are  frequently 
brought  to  the  position  of  asking  ourselves  whether  cardiac  degenera- 
tion be  present,  and  if  so,  its  extent,  variety,  and  nature. 

Our  diagnosis  must  be  determined  by  several  considerations  inde- 
pendently, perhaps  of  the  underlying  and  evident  gouty  changes.  It 
may  be  that  the  patient  has  been  a  free  liver,  is  of  corpulent  frame,  and 
has  indulged  more  or  less  and  for  a  considerable  time  in  the  use  of 
alcoholic  stimulants. 

These  conditions  would  tend  to  make  us  reasonably  sure  of  the 
presence  of  some  fatty  degeneration  of  muscular  fibre.  The  condition 
also  of  the  liver,  notably  where  it  is  torpid  and  enlarged  and  there  is 
possibly  some  additional  abdominal  enlargement  with  tension  of  the 
parietes,  would  make  us  suspect  cirrhotic  and  fatty  changes  in  this 
organ.  The  presence  of  ascites  may  remain  doubtful  for  weeks  and 
months,  and  never,  indeed,  be  accurately  determined.  Again,  in  a 
relatively  short  period  succussion  and  palpation  may  unquestionably 
reveal  abdominal  effusion  in  small  or  moderate  quantity.  In  these 
instances  the  pulse  may  never  have  increased  tension,  or  only  to  such 
slight  degree  that  our  tactile  sensations,  or  even  the  use  of  the  sphyg- 
mograph,  may  not  corroborate  our  suspicions,  but  simply  leave  us  in 
reasonable  doubt.  Here,  again,  it  is  the  skilful  touch,  the  keen  appre- 
ciation of  local  changes  which  proceeds  from  long,  careful  experience, 
or  the  expert  and,  may  be,  repeated  use  of  the  sphygmograph  which 
shall  solve  our  difficulty.  In  any  event,  but  particularly  where  our 
findings  are  positive,  we  believe  that  we  shall  detect  an  excess  of  fibroid 
tissue  in  the  heart  in  certain  spots  between  atrophied,  compressed,  or 
degenerated  fibres. 

The  cerebral  symptoms,  which  may  be  passing  or  more  or  less  per- 
manent, while  pointing  to  cardiac  degeneration,  do  not  tell  us  positively 
whether  the  fibroid   changes  or  fatty  ones  are  predominant.     If  the 


106  CHRONIC    MYOCARDITIS. 

mental  activity  of  the  patient  has  failed  slowly  and  evidently  for  many 
months,  if  the  memory  be  impaired,  somnolence  increasing,  and  even 
slight  mental  exertion  be  accompanied  by  geeat  fatigue,  slowness,  and 
difficulty  of  speech  and  obvious  lethargy,  we  are  inclined  to  the  opinion 
of  marked  fatty  degeneration,  always  supposing  the  other  signs  and 
symptoms  mentioned  are  present.  If  now  the  arterial  tension  remains 
high  the  coats  are  visibly  thickened,  knotty,  tortuous,  giving  proof  of 
decided  atheromatous  changes,  we  are  prone  to  believe  that  the  intra- 
cardiac condition  will  be  more  likely  that  of  chronic  myocarditis, 
with  marked  fibroid  changes.  Any  calcification  of  the  arteries,  as 
of  the  radial  or  temporal,  will  only  accentuate  and  confirm  this  judg- 
ment. 

This  condition  we  should  not  find  except  in  very  rare  instances,, 
unless  the  patient  were  one  already  of  advanced  years  or  the  gouty 
dyscrasia  were  intense  and  of  hereditary  origin  increased  by  bad  habits 
of  life,  speaking  mainly  from  the  hygienic  stand-point. 

In  some  instances  we  are  led  to  believe  that  on  autopsy  we  should 
find  the  coronary  arteries  notably  affected.  These  examples  are  espe- 
cially those  in  which  prsecordial  pain  and  anxiety  had  been  evident  at 
times  and  with  moderate  or  great  intensity. 

I  saw  a  patient,  not  long  ago,  a  professional  man,  about  fifty-five 
years  old,  who  gave  the  following  history  :  He  had  been  a  careful 
liver  so  far  as  food  and  alcohol  were  concerned,  but  had  for  many 
years  smoked  immoderately  and  kept  late  and  irregular  hours.  He  had 
done  much  hard  work  in  active  professional  life  and  in  a  literary  way. 
He  had  for  many  years  been  a  chronic  dyspeptic,  showing  itself  by 
slowness  and  impairment  of  digestion,  belchiDg  of  wind,  and  capricious 
appetite.  He  had  never  suffered  from  symptoms  of  heart  weakness  or 
distress.  Calling  to  see  him,  I  found  him  pacing  the  floor,  with  marked 
dyspnoea,  prsecordial  distress  and  great  mental  anxiety,  and  the  feeling 
of  impending  disaster.  The  hands  were  cold  and  the  face  blanched  ; 
the  pulse  was  regular  and  tolerably  full ;  the  radial  arteries  were  thick- 
ened and  there  was  apparently  increased  tension  ;  the  heart  was  en- 
larged, showing  hypertrophous  dilatation,  moderate  in  amount.  This 
attack  had  lasted  twelve  hours,  without  relief  spontaneously,  and  was 
increasing  in  intensity,  as  shown  by  the  augmented  distress.  The 
swallowing  of  numerous  soda-mint  tablets,  which  frequently  gave  relief 
to  simple  dyspeptic  conditions,  were  of  no  avail. 

I  prescribed  immediately  a  heart  tablet  of  strophantus,  digitalis, 
atropine,  and  nitroglycerin,  and  in  a  few  hours  there  was  great  relief. 
The  urine  during  the  attack  was  high-colored  and  concentrated,  but 
contained  neither  albumin  nor  sugar.  In  a  few  days  he  was  about  as 
usual.  I  advised  repose  from  work  and  careful  dietary,  with  the  use 
of  cardiac  stimulation  if  required.  In  a  short  while  he  was  better  than 
he  had  been  in  many  months  and  had  had  no  recurrence  of  his  angi- 
nose  symptoms. 

No  doubt,  to  my  mind,  this  patient  has  intracardiac  changes,  probably 
of  the  fibroid  type.     It  is  probable  also  that  this  coronary  circulation  is 


CHRONIC    MYOCARDITIS.  107 

defective  and  that  endarteritis  is  present.  Did  he  have  some  temporary 
and  incomplete  obstruction  of  one  or  other  of  these  arterial  branches  at 
the  time  of  his  attack?  This,  I  believe,  although  I  cannot  affirm  it.  I 
only  know  that  the  other  diagnosis  is  sufficient  to  explain  his  symptoms 
satisfactorily.  Probably  the  causes  enumerated  were  all  more  or  less 
contributory  to  the  development  of  the  attack.  Judging  by  the 
sequence  of  events,  I  believe  that  nervous  tone  to  the  heart  was 
partially  restored  by  relative  rest  from  work  and  that  the  stomachal 
condition  was  improved  by  appropriate  dietary.  The  use  of  the  cardiac 
tablets  during  the  attack  certainly  gave  marked  relief  and  possibly 
prevented  a  fatal  termination  due  to  complete  clogging  of  one  or  both 
main  arterial  coronary  branches. 

I  have  known  of  the  case  of  another  professional  man,  about  fifty 
years  of  age,  whose  habits  were  not  different  from  those  of  many  toler- 
ably successful  ones  at  this  period  residing  in  a  large  city.  He  worked 
moderately  but  not  unduly  ;  he  ate  and  drank  with  proper  selection 
and  due  regard  for  his  habits  and  peculiarities  ;  he  gave  himself  a  fair 
amount  of  recreation,  took  long  summer  vacations,  and  was  fond  of  the 
water  and  yachting.  At  times  he  had  very  slight  attacks  of  dyspnoea 
and  praecordial  anxiety,  which  never  meant  absolute  pain  or  great  dis- 
tress;  indeed,  these  mild  attacks  occurred  at  infrequent  intervals  and 
disappeared  spontaneously  and  in  a  few  minutes  or  hours  at  most.  One 
afternoon,  hastening  home  from  his  boat  on  the  river  to  dine  and  meet 
his  wife,  who  was  anxiously  awaiting  him,  as  he  was  late,  he  had  an 
attack  of  severe  angina  pectoris  and  died  suddenly  in  the  street. 

The  following  description  of  the  cardiac  changes  found  at  the  autopsy 
is  copied  textually  from  notes  kindly  given  me  by  the  pathologist : 

Moderate  degree  of  hypertrophy  of  left  ventricle.  Valves  compe- 
tent. Atheroma  in  mitral  valve  and  in  beginning  of  aorta.  In  latter 
situation  this  is  most  abundant  about  origin  of  coronary  arteries,  whose 
lumen  is  distinctly  encroached  upon  by  it.  On  opening  of  coronary 
arteries  atheroma  is  found  in  their  walls  extensively  beyond  their  origin. 
In  this  way  their  calibre  is  considerably  narrowed.  Microscopical 
examination  of  heart  muscle  reveals  increase  in  pigment  in  cells  about 
nuclei  and  a  slightly  granular  condition  of  muscle  cells  generally,  but 
no  distinct  fat.  There  is  no  obscuration  of  transverse  strise,  and  there 
is  no  increase  in  fibrous  tissue.1 

Analogous  instances  to  this  are  not  infrequently  met  with.  Of 
course,  the  precise  nature  and  the  degree  or  intensity  of  the  signs  and 
symptoms  experienced  during  life  vary  greatly.  In  a  similar  manner 
the  rapidity  or  suddenness  of  the  fatal  termination,  if  it  occur,  varies 
also  very  much.  Whenever  the  coronary  circulation  is  immediately  and 
wholly  obstructed  sudden  death  takes  place  and  one  of  several  findings 

1  The  findings  at  autopsy  are  here  unusual,  in  that  there  was  no  occluding  thrombus  and 
the  muscle  changes  are  slight. 


108  CHRONIC    MYOCARDITIS. 

is  evident  at  the  autopsy.  It  may  be  that  the  coronary  artery  is  filled 
up  with  an  embolic  plug,  which  has  its  origin  in  the  heart  either  from  a 
cardiac  thrombus  or  from  a  detached  portion  of  vegetation  from  a  dis- 
eased valve  or  cusp  of  the  mitral  or  aorta.  In  such  cases  the  coronary 
arteries  may  be  relatively  free  of  disease,  although  frequently  there 
may  be  even  here  a  concomitant  condition  showing  local  degeneration, 
though  slight  in  amount.  Wherever — and  this  occurrence  is  much 
more  usual — the  coronary  arteries  themselves  are  more  diseased,  show- 
ing inflammation,  thickening — endarteritis,  in  other  words — or  pro- 
nounced atheroma,  with  possible  calcification  at  certain  points,  they 
are  occlued  with  a  thrombus. 

The  arteries  may  be  occasionally  affected  and  narrowed  mainly  or 
entirly  at  their  orifices,  or  what  is  truer,  ordinarily,  the  coronary 
arteries  are  thickened,  tortuous,  atheromatous,  or  calcified  throughout 
the  larger  portion  of  their  distribution.  These  changes  have,  of 
course,  greatly  decreased  their  lumen  or  the  extent  of  their  calibre 
internally,  so  that  the  heart  has  been  imperfectly  nourished  by  an 
insufficient  blood  supply  for  a  long  period,  and  at  a  given  moment  a 
thrombus  forms  locally  and  almost  inevitably,  and  a  fatal  result  ensues, 
although,  of  course,  in  a  somewhat  less  rapid  manner  than  if  an  em- 
bolus has  been  the  immediate  and  efficient  cause  of  death. 

The  local  changes  of  the  heart  muscle  in  these  latter  cases  particu- 
larly partake  of  a  fatty  or  fibroid  character  and  are  more  or  less  local- 
ized or  disseminated  in  their  distribution,  according  to  modifying  gen- 
eral conditions.  Moreover,  the  time  during  which  the  changes  have 
taken  place  and  the  age  of  the  patient  have  much  to  do  with  the 
character  of  these  changes.  As  I  have  already  pointed  out,  it  is 
almost  impossible  prior  to  death  and  direct  examination  of  the  heart 
to  state  positively  just  what  shall  be  found,  so  far  as  the  precise  changes 
or  the  limitations  of  the  morbid  involvement  of  the  coronary  arteries 
and  heart  muscle  are  concerned. 

In  old  valvular  troubles  of  the  heart,  whether  they  be  of  the  nature 
of  stenosis  or  regurgitation,  in  chronic  pericarditis  where  the  adhesions 
are  tough  and  fibrous,  in  an  advanced  condition  of  hypertrophy  of  the 
heart,  with  probably  much  cardiac  dilatation,  fatty  degeneration  is 
almost  surely  going  to  occur  at  a  given  time,  provided  the  patient's 
life  is  sufficiently  prolonged;  then,  of  course,  notable  cardiac  weak- 
ness, prsecordial  distress  and  dyspnoea,  cyanosis,  infiltration  of  the  lower 
limbs,  weak,  unequal  and  irregular  pulse,  deficient  and  concentrated 
urinary  secretion,  are  some  of  the  numerous  painful  phenomena  with 
which  we  are  all  familiar. 

In  these  cases  we  naturally  expect  and  usually  find  post-mortem  far 
more  disseminated  degenerative  changes  of  the  heart  muscle  than  we 
do  in  the  instances  previously  cited.     As  a  rule,  the  left  ventricle,  and 


CHRONIC    MYOCARDITIS.  109 

more  particularly  the  portion  of  it  near  the  septum,  is  specially  affected. 
The  columns  carnese — the  papillary  muscles — are  frequently  reduced 
in  size,  changed  in  color,  soft  to  the  touch,  possibly  giving  a  greasy 
feel,  easily  torn  or  lacerated,  and  showing  to  the  naked  eye  indubitable 
evidences  of  fatty  degeneration  which  microscopical  investigation  will 
merely  serve  to  reaffirm. 

The  right  ventricle  may  also  be  degenerated  in  parts,  although  less 
frequently,  and  it  is  now  known  that  the  auricles  are  sometimes  in  a 
certain  degree  degenerated,  although  this  statement  was  formerly 
denied. 

If  there  be  chronic  myocarditis  present,  which  occasionally  occurs, 
the  heart  muscle  is  hard  and  resistant  in  spots  and  very  often  dimin- 
ished in  thickness  where  this  exists,  owing  to  the  deposit  of  fibrous 
tissue  which  has  practically  caused  many  muscular  fibres  to  atrophy, 
degenerate,  or  almost  or  completely  to  disappear. 

In  those  corpulent  people  who  have  accumulated  flesh  continuously, 
slowly,  and  in  large  amount,  the  heart  is  no  exception  to  the  great 
number  of  viscera  which  become  more  or  less  involved.  The  deposit 
of  fat  upon  and  around  the  heart  usually  seeks  at  first  those  regions 
where  fat  is  deposited  to  some  extent  normally,  and  particularly  in  the 
grooves  between  the  auricles  and  ventricles  and  along  and  over  the 
intraventricular  septum.  Later,  it  is  no  uncommon  finding  to  discover 
fat  under  the  epicardium  or  the  endocardium.  Whenever  this  occurs 
the  fatty  infiltration  has  extended  deeply  into  the  heart  muscle  and 
between  the  muscular  fibres  to  such  an  extent  that  the  force  of  the 
heart-beats  is  notably  lessened,  and  many  of  the  phenomena  which 
characterize  true  fatty  degeneration  of  the  cardiac  muscle  are  present 
during  life.  Not  a  very  long  time  passes  under  these  circumstances, 
unless  treatment  is  effective  in  checking  accumulation  of  fat  in  the 
tissues,  until  the  fat  deposited  penetrates  the  muscular  fibres  themselves 
and  produces  true  fatty  degeneration  of  the  heart. 

These  obese  persons  are,  therefore,  always  a  source  of  special  solici- 
tude to  us  when  we  take  care  of  them  in  any  of  their  ills.  All  acute 
diseases  in  their  instance  are  of  moment,  and  what  would  be  a  relatively 
simple  affair  with  a  thin  person  or  one  with  only  moderate  or  healthful 
embonpoint  is  apt  to  take  on  a  certain  degree  of  gravity.  A  slight 
bronchitis,  an  attack  of  influenza,  a  mild  rheumatic  seizure  or  a  limited 
attack  of  acute  pleurisy  will  almost  invariably  lessen  their  bodily 
strength  very  rapidly,  and  soon  their  respirations  are  much  quickened, 
their  pulse  becomes  rapid  and  weak,  and  their  cardiac  action  so  feeble 
as  to  require  immediate  and  frequent  stimulation.  The  only  way  to 
treat  such  patients  safely  is  to  suppress  all  bodily  exertion  as  much 
as  possible  for  a  time  and  to  lessen,  if  feasible,  their  mental  cares  and 
anxieties.     Even  without   any   marked  febrile  movement  they  should 


110  CHRONIC    MYOCARDITIS. 

be  put  to  bed  and  kept  there  until  the  acute  attack,  whatever  it  be, 
has  completely  passed,  during  several  days  at  least.  Of  course,  if 
there  be  marked  febrile  reaction  the  urgency  and  necessity  of  this 
action  on  the  part  of  the  attending  physician  is  even  far  more  impera- 
tive ;  and  here  it  is  well  to  remark  that  in  such  cases,  as  frequently  the 
rise  of  temperature  is  often  only  slight  or  moderate,  the  patient's  imme- 
diate and  nearest  relatives  are  not  at  all  alarmed,  and  not  infrequently 
consider  the  wise  and  careful,  conscientious  physician  a  great  alarmist 
when  he  is  merely  obeying  his  best  judgment  if  he  insists  absolutely 
upon  the  importance  of  following  out  strictly  his  orders. 

At  first,  in  some  of  these  cases,  and  leaving  out  attacks  of  acute 
trouble  for  the  while,  the  careful  examination  of  the  heart  physically 
will  not  permit  us  to  affirm  that  there  is  any  notable  cardiac  enlarge- 
ment ;  and  even  the  heart  sounds,  when  the  patient  is  in  his  usual 
health  and  free  from  physical  exertion  and  not  harassed  with  business 
or  other  cares,  will  not  show  any  special  weakness,  irregularity,  or 
notable  murmurs  ;  but  often  very  slight  exertion — as  going  up  stairs, 
climbing  a  hill,  hastening,  even  an  ordinary  walk  on  level  ground — 
causes  distress,  and  they  will  be  in  a  panting  condition  almost  imme- 
diately, become  dizzy  and  faint,  and  the  face 'is  suffused  with  an  undue 
pallor,  or  else  their  cheeks  and  eyes  are  congested  and  their  lips  are 
blue  and  cyanosed.  These  cases  we  all  see,  we  meet  them  every  day 
— and  often,  I  am  sorry  to  say,  do  not  guide  and  direct  them  intelli- 
gently. 

If  the  person  affected  with  obesity  is  young  I  do  not  believe,  as  a 
rule,  that  the  immediate  outlook  of  the  case  from  a  cardiac  stand-point 
has  usually  much  gravity ;  and  yet  even  then  we  must  not  ignore  the 
possible  outcome  and  the  danger  of  dilatation  of  the  heart  resulting — 
more  or  less  lasting  and  important — unless  we  insist  upon  proper 
dietary,  exercises,  and  judicious  medication.  But  in  women,  near  the 
climacteric  especially,  and  in  men  near  or  past  middle  life,  we  cannot  be 
too  formal  about  our  protests  to  be  careful  and  heed  judicious  medical 
counsels ;  otherwise  we  shall  have  soon  to  deplore  an  evident  cardiac 
enlargement  and  dilatation,  which  from  a  prognostic  stand-point  is  cer- 
tainly very  grave,  as  the  underlying  cause  is  often  fatty  degeneration 
of  cardiac  muscular  fibre,  and  in  view  of  the  age  and  condition  of  the 
patient  is  very  difficult,  not  to  say  impossible,  to  remove. 

In  young  girls,  particularly,  obesity  is  apt  to  follow  acute  disease  like 
scarlet  fever  or  typhoid  and  to  be  allied  with  chlorosis.  This  ansemia 
is  sometimes  corrected  by  proper  treatment  without  too  great  lapse  of 
time;  again,  it  is  most  persistent  and  resists  all  our  efforts  for  months 
and  years.  During  this  period  such  girls  are  liable  to  syncopal  attacks 
and  other  symptoms  which  surely  indicate  pronounced  cardiac  weak- 
ness and  cause  much  distress  and  anxiety  to  all  concerned — patient, 


CHRONIC    MYOCARDITIS.  Ill 

relatives,  and  physicians.  In  older  patients  the  blood  may  be  of  rela- 
tively good  quality  and  not  seemingly  add  to  the  distressing  or  merely 
uncomfortable  symptoms. 

In  some  women  who  have  profuse  menstruation  ;  in  those  who  are 
married  and  have  had  several  children  ;  in  women  at  the  time  of  the 
menopause — the  amount  of  blood  often  lost  at  the  monthly  flow  is 
excessive,  and  the  result  is  that  the  bodily  strength  is  greatly  diminished 
and  the  blood  examination  shows  great  diminution  in  haemoglobin  and 
the  number  and  appearance  of  the  red  cells. 

Here,  again,  I  have  no  doubt  that  the  anaemia  thus  produced  hastens 
considerably  fatty  degeneration  of  heart  muscle  and  the  subsequent 
development  of  cardiac  dilatation.  In  these  instances,  if  for  some 
reason  the  patient  is  obliged  to  submit  to  an  operation  and  take  an 
anaesthetic,  of  course  the  attending  physician,  surgeon,  and,  above  all, 
the  giver  of  ether  or  chloroform  or  even  nitrous  oxide  should  be  par- 
ticularly careful.  In  uterine  fibroids  which  require  operation  I  would 
urge  more  than  ordinary  solicitude  in  administering  anaesthetics,  and 
especially  in  corpulent  women  about  middle  age.  These  women  are 
affected  with  several  conditions  which  are  apt  to  produce  fatty  degen- 
eration of  the  heart.  It  may  be  that  prior  to  the  operation  the  heart 
had  been  thoroughly  examined  and  was  declared  competent  and  prob- 
ably free  from  more  than  a  considerable  degree  of  fatty  infiltration, 
making  part,  as  it  were,  of  the  increased  fatty  accumulation  in  the 
body  not  only  in  the  cellular  tissue  under  the  skin,  but  also  of  several 
of  the  other  viscera.  During  the  course  of  the  anaesthesia,  however, 
and  subsequent  also  to  the  operation,  general  phenomena  of  cardiac 
weakness  showed  themselves,  which,  without  doubt,  at  times  hastened 
or,  indeed,  ended  the  fatal  ending  of  the  case. 

Whether  under  these  circumstances,  as  in  one  unfortunate  case  I 
have  in  mind,  the  cardiac  failure  would  at  all  explain  the  rise  of  tem- 
perature and  local  evidences  of  peritonitis  which  developed,  or  whether 
these  latter  phenomena  were  merely  due  to  some  imperfection  in  the 
operative  technique,  or,  indeed,  to  penetration  and  absorption  of  septic 
material  in  the  abdominal  cavity,  I  am  not  wholly  convinced.  What 
we  do  know  is  this,  viz.,  when  a  sudden  and  great  loss  of  blood  occurs, 
accompanying  the  severe  shock  to  the  nervous  system,  and  indeed  the 
whole  organism,  inseparable  often  from  the  results  of  a  very  severe 
operation,  conditions  arise  which  may  readily  serve  to  explain  increased 
temperature,  paralysis  of  the  bowels,  local  congestions  of  intense  degree 
leading  rapidly  to  inflammation,  the  formation  possibly  of  purulent 
infiltration,  and  death. 

Our  overwrought  theories  of  microbic  infection,  it  appears  to  me, 
make  us  partially  blind  to  the  broad  notions  of  general  pathological 
physiology,  which   I  am  confident   will   outlive   narrow  and   confined 


112  CHRONIC    MYOCARDITIS. 

notions  of  the  origin  and  development  of  disease,  and  so  it  may  be  in 
the  case  referred  to. 

In  no  condition  do  we  dread  more  the  development  of  fatty  degenera- 
tion of  the  heart  than  in  that  of  chronic  alcoholism.  In  all  acute  dis- 
eases, but  particularly  so  in  the  pneumonia  of  adults,  when  we  know 
we  have  to  do  with  a  chronic  alcoholic,  our  prognosis  of  the  outcome  of 
the  case  should  always  be  carefully  guarded.  No  matter  how  mild  the 
attack  may  apparently  be  in  the  beginning — no  matter  how  hopeful  we 
might  be  in  other  cases  as  to  the  future  course  of  the  disease — in  view, 
perhaps,  of  the  small  area  of  lung  involvement  and  the  mildness  of  the 
general  reaction  present,  danger  is  always  lurking  and  may  show  itself 
almost  at  any  moment,  either  during  the  acute  stage  of  the  pneumonia 
or  in  the  early  convalescent  period,  by  sudden  pulmonary  congestion  or 
oedema,  with  accompanying  heart-failure ;  or,  indeed,  the  heart  itself 
may  rapidly  or  suddenly  cease  to  beat,  and  the  patient  die  in  a  syncopal 
attack  with  dyspnoea  and  apparent  asphyxia,  or  a  convulsive  seizure 
resembling  closely  a  so-called  uremic  attack.  The  slightest  effort  may 
bring  on  such  a  result.  Going  to  stool,  raising  himself,  or  turning 
over  in  bed  without  the  help  of  a  nurse  may  be  among  several  efficient 
causes  which  bring  about  instant  dissolution.  Again,  the  fatal  occur- 
rence may  come  about  without  any  accidental  circumstances  whatever 
to  which  we  would  direct  attention. 

Not  only  in  acute  diseases  are  these  statements  true,  but  they  are 
almost  equally  true  when  the  individual  has  apparently  been  in  his  usual 
health.  Thus  it  is  we  hear  of  many  cases  of  sudden  death  attributed 
to  so-called  heart-failure,  which  means  nothing  tangible  or  obvious,  but 
which  should  mean  fatty  cardiac  degeneration.  If  an  autopsy  is  made 
it  will  frequently  demonstrate  the  fact  beyond  reasonable  doubt. 

In  certain  autopsies  carefully  conducted,  so  far  as  visible  appearances 
are  concerned,  a  report  is  occasionally  returned  that  no  sufficient  cause 
of  death  has  been  discovered.  The  heart  is  about  of  normal  size, 
there  is  no  valvular  disease,  and  the  cardiac  fibre  does  not  seem  notably 
affected.  There  is  assuredly  no  pallor  of  the  heart  muscle ;  the  heart 
may  not  flatten  out  on  the  table  and  the  muscle  may  not  be  easily  torn 
or  lacerated  ;  indeed,  the  heart  muscle  is  deeply  stained  or  of  more  than 
ordinary  deep  red  coloration.  In  some  instances  this  staining  is  due. 
simply  to  the  imbibition  of  the  muscular  fibres  with  the  coloring-matter 
of  the  blood  due  to  changes  caused  in  this  fluid.  While  this  appear- 
ance is  oftener  present  in  acute  febrile  disease  than  it  is  where  no  such 
intercurrent  complication  has  taken  place,  yet  the  cardiac  appearances 
may  be  as  I  have  described  them  in  chronic  alcoholics  who  have  died 
suddenly. 

The  microscopical  examination  of  the  cardiac  fibres  in  these  instances, 
if  made — and  it  always  should  be  made — will  not  infrequently  reveal 


CHRONIC    MYOCARDITIS.  113 

manifest  granular  or  fatty  degeneration  of  muscular  fibres,  possibly 
limited,  but  more  usually  disseminated.  Whenever  the  changes  are 
limited  we  should  be  careful  to  examine  the  condition  of  the  coronary 
circulation,  and  frequently  there  will  be  found  endarteritis  or  athero- 
matous changes. 

In  the  senile  heart,  especially  among  those  persons  who  have  led  a 
moderately  careful  and  regular  life,  we  are  more  inclined  to  diagnose 
fibrous  changes  than  fatty  ones  if  the  heart  begins  to  show  decided 
weakness,  irregularity,  and  intermittences.  With  this  condition  there 
may  be  moderate  enlargement — usually  hypertrophous  dilatation. 
There  may  be  no  abnormal  cardiac  murmurs,  and  frequently  the  puke, 
instead  of  being  irregular  and  weak,  may  be  of  good  tension  and  very 
regular,  showing  trouble  only  by  a  little  lack  of  fulness  and  undue 
slowness.  Of  course,  the  arterial  coats  both  at  the  radials  and  temporals 
may  be  thickened,  tortuous,  and  stand  out  prominently,  owing  to  the 
shallow  layer  of  subcutaneous  cellular  tissue. 

The  urine  in  these  cases  may  be  in  fairly  good  quantity,  but  is  ordi- 
narily of  somewhat  low  specific  gravity,  without  sugar  or  albumin.  An 
occasional  granular  or  hyaline  cast  is  often  discovered.  With  a  ten- 
dency to  constipation,  which  often  exists,  the  quantity  of  urine  elimi- 
nated in  twenty-four  hours  will  sometimes  be  decidedly  below  normal. 

With  any  little  fatigue,  with  any  slight  error  of  diet,  with  any 
prolonged  exposure,  with  any  excessive  heat  or  cold,  with  any  rapid 
change  of  temperature  even,  these  old  people  are  apt  to  feel  poorly. 
They  lose  appetite,  they  sleep  less  well,  their  bronchial  secretion  is 
increased  so  as  to  produce  annoying  cough  for  some  days,  they  are 
apt  to  become  lethargic  and  inclined  to  doze  frequently,  and  it  is  not 
uncommon  to  have  them  complain  of  feeling  dizzy  or  faint.  All  these 
symptoms  are  unquestionably  due  in  some  instances  at  least  to  cer- 
tain fibroid  changes  in  the  heart  muscle.  These  changes  are,  how- 
ever, not  usually  limited  there ;  they  are  more  or  less  disseminated 
everywhere  in  the  arterio-capillary  system,  and  several  of  the  different 
viscera  are  notably  affected,  and  particularly  is  this  true  of  the 
kidneys,  the  liver,  and  the  lungs.  We  have  in  these  cases  the  best 
expression,  without  doubt,  of  the  general  disease  so  ably  described 
originally  by  Gull  and  Sutton  and  so  well  added  to  by  the  labors  of 
George  Johnson  and  other  able  writers. 

As  regards  the  effect  of  syphilis  in  producing  cardiac  degeneration, 
either  of  the  fibroid  or  fatty  type,  I  have  very  little  to  say  from  the 
point  of  view  of  my  own  personal  observation  and  experience.  In  a 
few  rare  instances,  it  is  true,  where  the  syphilitic  poisoning  was  intense 
and  the  constitutional  effects  had  become  wide-spread  by  reason  also  of 
its  duration,  I  have  seen  the  internal  organs  evidently  much  affected. 

Syphilitic  gummata  of  the  liver  I  have  occasionally  observed,  and 


114  CHRONIC    MYOCARDITIS. 

in  connection  therewith  there  have  been  fatty  and  fibroid  changes. 
Undoubtedly  the  same  products  may  occur  in  the  heart  walls,  although 
very  infrequently  in  the  ordinary  routine  of  general  hospital  or  private 
practice.  Its  possibility,  however,  should  be  kept  in  view,  and  where- 
ever  we  have  to  do  with  those  changes  in  deep-seated  organs  of  syph- 
ilitic origin  which  cleary  show  its  special  virulence  we  should  pay 
particular  attention  to  the  condition  of  the  heart.  If  there  be  signs 
and  symptoms  pointing  clearly  to  cardiac  weakness  coming  on  slowly 
and  increasing  constantly  it  is  good  clinical  conduct  to  have  our  mind 
alive  to  the  possibility  of  an  intracardiac  gumma  and  to  the  fatty  and 
fibroid  changes  which  may  depend  upon  or  result  therefrom. 

After  what  I  have  written,  the  prognosis  and  treatment  of  these 
structural  changes  should  be  considered.  In  general  it  may  be  said 
that  if  the  process  has  come  on  with  some  rapidity,  or  if  the  cause  be 
possible  of  removal,  the  prognosis  is  far  less  grave,  at  least  perspec- 
tively,  than  if  the  contrary  conditions  are  true.  Of  course,  in  the 
fatty  change  of  the  heart,  which  I  believe  possibly  or  probably  exists  to 
a  certain  degree  at  least  in  a  few  anaemic  young  women,  this  condition 
is  undoubtedly  curable  in  a  shorter  or  longer  time  by  judicious  methods 
-of  treatment.  If  the  anaemic  state  should,  on  the  contrary,  become  of 
a  more  advanced  or  pernicious  type,  we  all  know  that  while  we  may 
and  do  obtain  temporary  good  effects,  which  for  a  while  at  least  may 
seem  to  promise  a  permanent  cure,  our  hopes  are  apt  to  be  in  vain. 

This  is  thus  far  the  history  of  the  medicinal  effects  of  large  and  in- 
creasing doses  of  arsenic  and  the  use  of  intestinal  antiseptics  according 
to  the  method  of  Hunter  in  the  treatment  of  pernicious  anaemia.  The 
able  and  exhaustive  report  of  Cabot  before  the  Association  of  American 
Physicians,  May,  1900,  would  serve  only  to  confirm  the  correctness 
and  sadness  of  this  view. 

In  all  instances,  of  course,  where  the  anaemic  condition  and  the 
accompanying  cardiac  degeneration,  probably  fatty,  depends  upon  or 
is  occasioned  by  malignant,  incurable  disease,  so  recognized  at  the 
present  time,  we  cannot  properly  hope  for  any  amelioration  of  the 
cardiac  changes.  In  most  instances  where  the  alcoholic  habit  has  been 
largely  instrumental  in  bringing  on  signs  and  symptoms  of  cardiac 
fatty  degeneration  and  similar  changes  in  other  viscera — if  these 
changes  are  not  too  far  advanced  and  if  the  alcoholic  habit  be  entirely 
suppressed — we  may  reasonably  hope  in  many  examples  for  a  measur- 
able degree  of  improvement  in  the  physical  condition  of  the  patient  and 
possibly  for  a  complete  cure.  This  happy  result  can  only  be  obtained 
with  considerable  time,  however,  and  by  absolute  attention  to  abstemi- 
ous habits  of  life,  and,  above  all,  by  complete  abstention  from  alcohol 
in  future.  Of  course,  if  the  alcoholic  habit  has  been  an  excessive  one 
and  long  continued,  and  if  the  patient  has  already  reached  middle  life 


CHRONIC    MYOCARDITIS.  116 

or  passed  beyond  it,  the  ultimate  outlook  of  the  case  is  far  less  hopeful. 
In  this  matter,  however,  personal  idiosyncrasy  and  constitutional  ten- 
dencies should  always  be  considered  and  much  weight  given  to  their 
due  estimate. 

I  have  known  certain  individuals  to  have  a  pronounced  alcoholic 
habit  of  many  years'  duration,  and  yet  during  a  large  portion  of  the 
time  they  have  shown  no  morbid  symptoms  or  signs  of  special  moment 
resulting  therefrom.  When  morbid  phenomena  develop  finally  in  these 
cases,  pointing  unerringly  to  involvement  and  degeneration  of  the 
heart  muscle,  I  still  feel  a  reasonable  hope  that  they  may  be  able  to 
arrest  their  disease,  provided  always  that  I  can  persuade  them  to 
restrain  absolutely  their  alcoholic  appetite. 

In  other  cases  so  soon  as  the  cardiac  degeneration  is  clearly  present 
the  onward  march  of  the  disease  takes  place  apparently  without  halt 
or  hinderance.  The  march  onward  and  downward  may  be  slow  or 
rapid,  but,  unfortunately,  it  is  sure,  and  our  best  remedial  means  are 
ineffective  to  delay  or  arrest  its  course. 

In  certain  obese  persons,  by  a  proper  system  of  diet  and  exercise  and 
suitable  cardiac  tonics  at  times  combined  with  the  continuous  and 
judicious  inhalation  of  oxygen  during  weeks  and  months,  we  may 
sometimes  obtain  very  good  effects.  The  prolonged  use  of  iodide  of 
potassium  in  these  cases,  given  in  moderate  doses,  always  supposing  it 
is  well  borne  by  the  stomach  and  eliminative  organs  (skin,  lungs,  and 
kidneys),  is  in  the  judgment  of  many  capable  observers  very  useful 
and  takes  the  place  oftentimes  of  nitroglycerin  and  the  nitrites  with 
great  advantage. 

A  few  observations  of  individuals,  young  or  past  middle  life,  have 
made  me  believe  that  the  treatment  of  Nauheim  in  well-selected  cases 
and  managed  with  discretion  and  good  judgment  and  with  a  mental 
eye,  single  and  devoted  to  the  best  good  of  the  patient,  has  been  un- 
questionably of  great  use  for  a  time.  The  great  risk  of  this  spa  treat- 
ment, as  of  all  others,  resides  in  the  fact  that  even  intelligent,  culti- 
vated physicians,  here  as  elsewhere,  become  in  a  sense  the  victims  of 
their  own  exaggerated  enthusiasm,  and  when  a  patient  comes  under 
their  care  they  are  apt  to  push  their  treatment  inconsiderately  perhaps, 
and  sometimes  too  far. 

Again,  it  occurs — I  have  known  such  a  case — an  individual  past  the 
meridian  of  life  had  been  sent  to  Nauheim  for  treatment  by  his  family 
physician,  and  although  the  patient  when  he  reached  the  springs  was 
in  no  condition  to  go  through  the  spa  treatment — or  originally,  even, 
he  was  not  a  suitable  case  for  treatment,  either  owing  to  his  precon- 
ceived notions  or  the  stress  he  laid  upon  carrying  out  what  he  was 
ordered  from  home  to  do — led  the  local  practitioner  of  Nauheim  to 
permit   the  following  up  of  what   perhaps,  if  his  better  judgment  had 


116  CHRONIC    MYOCARDITIS. 

acted   coolly  and  deliberately,   he  would   not   have   permitted,    or   in 
another  case  have  only  permitted  in  a  very  limited  measure. 

In  some  cases  one  treatment  at  Nauheim  may  be  decidedly  useful, 
but  unfortunately  has  not  been  completely  successful  in  establishing  a 
cure.  Such  a  patient  is  sometimes  told  to  return  another  season,  or 
another,  and  better  results  may  or  will  be  obtained.  This,  unhappily, 
is  an  error  fruitful  of  bad  consequences.  The  patient  has  really 
obtained  all  the  good  possible  from  the  saline  carbonic  acid  baths  and 
the  regulated  resistant  movements.  It  would  have  been  far  better  for 
these  persons,  in  my  judgment,  if  they  had  remained  away  from  the 
spa  later  and  if  they  had  sought  from  other  means  all  the  improve- 
ment they  could  fairly  hope  for. 

It  is  the  wise,  conscientious  physician,  who  is  thoroughly  familiar 
with  the  personality,  habits,  and  surroundings  when  at  home  of  these 
patients,  who  should  really  guide  and  direct  them.  I  say  it  most 
regretfully  that  oftentimes  his  voice  is  like  as  one  "  crying  in  the 
wilderness,"  and  the  wisdom  of  his  forethought,  wide  knowledge,  and 
clear-sightedness  is  rarely  or  perhaps  never  fully  recognized.  In 
senile  changes  of  degenerative  type  affecting  the  heart,  and  especially 
where  interstitial  fibroid  changes  occur,  accompanied  usually,  as  I  have 
already  said,  by  more  or  less  general  changes  throughout  the  whole 
arterial  system,  a  wise  conservatism  should  always  prevail.  It  is  utter 
foolishness  to  suppose  that  we  can  modify  in  any  appreciable  degree 
what  has  very  slowly  and  surely  taken  place,  and  what  is,  after  all, 
many  times  only  the  outward  and  visible  expression  of  the  progress 
at  times  or  the  result  of  "  anno  domini,"  from  which  man  no  more 
than  other  animals  is  exempt. 

There  is  a  natural  growth  and  natural  decay,  and  these  fibroid 
changes  in  the  heart  and  vascular  circulation  are  to  be  wisely  regarded 
as  nature's  showing  in  due  season.  In  such  cases,  therefore,  treat 
symptoms  as  they  arise  with  the  hope  of  temporary  relief  and  tem- 
porary benefit  many  times,  but  no  more  hope  to  arrest  or  change  the 
inevitable  permanently  than  to  change  the  river  permanently  in  its 
course  by  an  insignificant  and  temporary  dam.  In  the  fatty  degeneration 
which  complicates  chronic  valvular  cardiac  conditions,  which  is  either 
the  cause  or  the  result  of  cardiac  hypertrophy  or  dilatation,  something 
may  still  be  done. 

The  general  nutrition  of  these  patients  may  be  kept  up  by  suitable 
food,  and  their  emunctories  may  be  properly  stimulated  when  required 
by  baths,  diuretics,  and  general  laxatives.  Breathing  pure  air  and  gentle 
exercise  in  walking  will  sometimes  prove  remedial.  The  blood  should 
be  kept  in  good  condition  and  tonics  may  be  required.  Heart  stimu- 
lants are  often  temporarily  useful.  In  the  event  of  evidence  that  the 
condition   is    not    progressing    favorably,   strychnine   is   advantageous 


CHRONIC    MYOCARDITIS.  117 

when  continued  for  some  time,  with  occasional  interruptions,  in  moder- 
ate doses.  Where  there  is  much  arterial  tension,  with  marked  dysp- 
noea, iodide  of  potassium,  if  well  borne,  will  give  temporary  relief  and 
occasionally  proves  permanently  beneficial.  All  sudden  or  great  efforts 
should  be  most  carefully  avoided,  and  especially  is  this  true  in  the 
secondary  great  hypertrophy  which  follows  aortic  regurgitation,  when- 
ever the  heart  shows  that  its  walls  have  become  hopelessly  degenerated. 
In  these  instances  it  is  that  many  sudden- deaths  occur,  as  the  records 
of  our  hospitals  abundantly  show,  as  well  as  occasionally  experience  in 
private  practice. 

In  cases  of  suspected  syphilitic  degeneration  affecting  the  cardiac 
muscle,  iodide  of  potassium,  freely  given,  or  the  mixed  treatment  wisely 
ordered  according  to  circumstances,  should  be  our  main  reliance. 

In  writing  the  foregoing  paper  I  might  have  insisted  more  than  I 
have  done  upon  the  purely  pathological  aspects  of  my  subject.  I  might, 
indeed,  have  given  a  careful  description  of  pathological  findings  in 
these  cases  at  the  autopsy  when  it  was  made,  and  especially  when  made 
with  particular  reference  to  the  condition  of  the  cardiac  walls  and  the 
coronary  circulation.  To  have  done  so  would  have  lengthened  my 
paper  unduly,  and  would,  moreover,  have  taken  away  perhaps  part  of 
the  interest  attaching  to  it  as  a  clinical  study,  upon  which  I  would  place 
special  emphasis. 

Having  said  this  by  way  of  an  explanation  I  would  now  crave 
attention  for  a  few  words  from  the  point  of  view  of  the  gross  and 
minute  lesions  present  in  the  cardiac  muscles  in  different  instances. 
Wherever  the  heart  is  notably  affected  with  fibroid  changes  the  muscle 
there  becomes  tougher  and  more  resistant,  besides  showing  thinning  of 
heart  walls  in  places.  In  the  spots  thus  affected  there  is  a  yellow- 
whitish  coloration,  which  indicates  somewhat  the  probable  nature  of 
the  degeneration.  The  degeneration  is  prone  to  occur  in  patches  and 
especially  in  certain  regions  of  the  left  ventricle  and  near  the  septum 
and  apex  than  elsewhere.  Under  the  microscope  the  parts  affected  are 
shown  often  to  be  almost  wholly  composed  of  fibrous  tissue. 

In  other  cases,  while  the  fibrous  tissue  is  in  great  excess  between  the 
muscular  fibres,  the  latter  still  are  present  but  atrophied  or  degenerated 
more  or  less.  The  nucleus  has  sometimes  disappeared  as  well  as  the 
strise,  and  there  may  be  more  or  less  pigmentary  deposit  in  the  form 
of  granules,  regularly  or  irregularly  distributed.  Wherever  the 
nucleus  of  the  muscle  still  exists  the  pigmentary  granules  are  apt  to 
be  present  in  larger  numbers  about  it  than  elsewhere. 

The  primary  fibres  are  occasionally  almost  homogeneous  in  appear- 
ance. Alongside  of  fibres  much  atrophied  or  degenerated  there  may 
be  others  relatively  healthy. 

In  chronic  fatty  degeneration  of  the  heart  muscle,  especially  if  it  is  at 


118  CHRONIC    MYOCARDITIS. 

all  advanced  as  to  its  stage,  the  color  of  the  muscle  is  notably  pale  and 
yellow  in  places.  Sometimes,  however,  where  the  changes  are  not  so 
far  advanced,  at  least  in  spots,  but  more  generally  disseminated,  the 
heart  muscle,  particularly  of  the  ventricles  where  the  degeneration  is 
most  pronounced,  is  less  changed  in  color  from  the  normal.  However, 
in  these  instances  the  muscle  has  lost  its  consistence,  is  very  flabby, 
and  the  heart  flattens  out  and  loses  somewhat  its  healthy  outline  on 
the  table  ;  beside  it  has  lost  resistance  and  is  easily  torn  and  lacerated. 
Under  the  microscope  the  diseased  fibres  may  show  very  numerous 
granules,  or  at  an  ulterior  stage  these  granules  may  be  replaced  by  many 
glistening,  shiny,  very  refringent  round  bodies  of  large  calibre,  which 
evidently  are  oily  or  fatty.  Here,  again,  the  nucleus  of  the  muscle  may 
or  may  not  have  become  degenerated  or  have  disappeared  entirely. 
The  same  is  true  of  the  lateral  strise  and  the  longitudinal  fibrillations. 

There  may  sometimes  be  an  overgrowth  of  pigment  granules.  These 
granules  may  be  deposited  in  the  muscular  fibre  itself  or  in  the  inter- 
stitial connective  tissue  between  the  fibres.  The  pigmentary  granules 
may  be  more  or  less  irregularly  placed.  Usually  there  are  a  larger 
number  near  the  muscle  nucleus.  Occasionally  the  whole  fibre  may 
be  larger  than  normal  and  appear  almost  entirely  homogeneous. 

Alongside  of  some  fibres  completely  degenerated  there  are  others  which 
are  relatively  healthy  or  diseased  only  in  parts.  The  connective  tissue 
between  the  fibres  in  typical  fatty  degeneration  of  the  muscle  is  usually 
not  much,  if  at  all,  increased  in  quantity.  In  other  cases,  especially 
where  there  are  fibroid  changes  throughout  the  vascular  system  and  in 
different  viscera,  there  may  be  a  considerable  increase  of  interstitial 
connective  tissue  and  pronounced  fatty  degeneration. 

For  further  and  more  complete  and  accurate  knowledge  of  the 
pathology  of  these  cases  I  would  direct  my  readers  to  the  best  modern 
treatises  on  cardiac  disorders,  among  which  that  of  Gibson  seems  to 
me  particularly  valuable.  To  this  author  I  feel  especially  indebted 
for  much  valuable  knowledge,  which  I  have  not  hesitated  to  utilize 
and  to  whom  I  now  give  full  credit. 


ANGINA  PECTORIS. 


Angina  pectoris,  in  its  typical  form,  is  in  my  experience  a  very 
rare  disease.  Pseudo-angina,  or  what  resembles  it  at  times,  cardiac 
asthma,  is  not  infrequent.  Although  angina  pectoris  is  described 
among  the  neuroses  of  the  heart  by  authors,  this  view  in  my  judgment 
is  frequently  erroneous.  In  the  great  majority  of  instances  where 
angina  is  present  there  exist  also  organic  changes  of  the  coronary  cir- 
culation, of  the  cardiac  muscular  fibres,  or  a  lesion  of  the  aortic  orifices. 

I  should  be  loath  to  admit,  except  in  a  very  exceptional  way,  the 
existence  of  true  angina  purely  of  neurotic  origin.  On  the  other  hand, 
pseudo-angina  is  very  frequently  of  this  provenance,  accompanied  by 
symptoms  of  flatulent  dyspepsia.  It  must  be  understood,  however, 
that  there  are  cases  on  the  border-line  in  which,  during  life,  we  have 
great  difficulty  in  pronouncing  as  to  what  symptoms  are  of  nervous 
origin  and  what  are  clearly  due  to  organic  changes  of  the  heart  or 
arteries. 

In  many  such  instances,  unfortunately,  even  if  death  occurs,  we  are 
uot  always  able  to  obtain  verification  of  clinical  facts  by  the  results  of 
an  autopsy.  Hence,  certain  theories  are  brought  to  the  front  which 
have  no  basis  in  actual,  reliable  observations  from  the  dead-house. 

One  statement  is  certainly  true  of  angina,  viz. :  that  it  has  usually 
connected  with  it  an  element  of  spasm  or  sudden  intracardiac  pressure 
which  separates  it  notably  from  conditions  which,  in  many  ways,  are 
similar,  and  yet  from  this  stand-point  differ  manifestly  in  a  greater  or 
less  degree.     Of  the  truth  of  this  statement  we  shall  be  convinced  later. 

In  general,  it  may  be  stated  that  pain,  properly  speaking,  does  not 
characterize  organic  disease  of  the  heart  as  we  commonly  meet  it.  Of 
course,  there  may  be  more  or  less  prsecordial  anxiety  or  oppression,  or 
there  may  be  pain  in  the  vicinity  which  is  of  stomachal  or  hepatic 
origin;  but  acute  cardiac  pain  is  very  rare.  For  this  reason  it  has 
become  almost  an  axiom  for  clinicians  to  say  when  acute  cardiac  pain  is 
complained  of,  it  is  more  than  likely  no  organic  disease  of  the  heart  is 
present.  Perhaps  this  affirmation  is  too  positive  or  dogmatic,  since  I 
am  confident  functional  distress  may  occur  which  is  dependent  upon 
obvious  tissue  changes. 

In  true  angina  the  pain  is  very  characteristic,  and  as  I  have  said, 
ordinarily  means  organic  changes  of  the  heart  structure.     First  of  all, 


120  ANGINA    PECTORIS. 

the  pain  of  angina  is  marked  by  its  great  intensity.  In  no  other  dis- 
ease, perhaps,  is  this  so  true.  When  the  anginoid  attack  occurs,  if  the 
patient  is  walking  or  exercising  in  any  way,  he  stops  immediately  and 
holds  himself  as  quiet  as  possible,  only  taking  hold  almost  involun- 
tarily at  times,  so  great  is  his  distress,  of  the  nearest  object  which  will 
give  him  support.  Otherwise,  he  may  merely  stand  rigidly,  having 
come  to  a  short  stop,  with  his  arms  lying  unconsciously  by  his  side,  or 
else  one  hand  is  pressed  firmly  in  the  precordial  region,  as  if  to 
ameliorate  in  a  measure  the  subjective  agony  by  so  doing.  During  the 
attack  the  pectoral  and  other  muscles  of  respiration  scarcely  move,  and, 
indeed,  breathing  comes  almost  to  a  stand-still  for  a  while.  In  this 
we  perceive  at  once  the  great  dissimilarity  with  an  attack  of  cardiac 
asthma,  in  which  the  efforts  to  breathe  are  so  forcible  and  striking. 
And  yet  there  are  numerous  instances  in  which  the  cardiac  asthmatic 
features  are  most  notable  and  where  the  "angina  sine  dolore"  of 
Gairdner  is  also  present,1  as  Osier  states,  after  a  masterly  summary  of 
the  differential  diagnosis  of  these  two  states,  "  when  we  recall  to  mind 
the  features  of  the  attack  in  cardiac  asthma  and  in  certain  anginal 
seizures,  the  similarity  of  the  condition,  as  Huchard  remarks,  to  an 
acute  emphysema,  the  views  of  Von  Basch2  appear  to  possess  at  least  a 
reasonable  probability  "  (p.  85). 

The  locality  of  the  pain  in  angina  is  not  always  the  same.  Fre- 
quently it  is  located  over  the  precordial  region.  At  times,  however,  it 
may  be  situated  in  the  upper  portion  of  the  chest,  or  again,  but  in  rela- 
tively few  instances,  it  may  stretch  like  a  heavy  bar  across  the  xiphoid 
cartilage  and  the  adjacent  structures.  Under  these  circumstances  the 
pain  may  radiate  directly  through  the  chest  and  be  felt  even  in  the 
back.  The  pain  has  been  likened  to  a  heavy  weight  or  crushing 
pressure,  as  though  the  thoracic  parietes  must  almost  meet.  The  pain 
is  also  said  to  resemble  that  of  some  terrible  griping,  as  though  the  heart 
were  held  firmly  in  the  clutch  of  some  terrible  monster.  All  these  sen- 
sations, and  numerous  others,  have  been  described  and  dwelt  upon  by 
writers,  who  doubtless  have  used  their  imagination  at  times  to  supply  the 
descriptive  powers  of  the  patient.  Suffice  it  to  add  that  the  pain  is  of 
a  frightful  sort  and  quite  unlike  any  other  we  are  familiar  with.  Often 
the  radiation  of  the  pain  is  toward  the  left  arm,  and  in  that  case  is 
usually  carried  through  the  forearm  also  and  to  the  fingers.  The  ring 
and  little  fingers  are  said  to  be  usually  affected.  Very  rarely  the  pain 
extends  to  the  right  arm.  When  it  does  it  radiates  likewise  in  one  or 
other  direction  mentioned. 

According  to  Broadbent,  the  pain  of  angina  often  originates  in  the 

1  Osier.    Angina  Pectoris  and  Allied  States,  p.  82. 

*  These  are :  "  Cardiac  dyspnoea  follows  swelling  and  diminished  elasticity  in  the  lungs." 


ANGINA    PECTORIS.  121 

left  wrist,  and  from  there  travels  upward  through  the  left  arm  and 
toward  the  chest — or  again,  as  Osier  states,  although  originating  in  the 
chest,1  "  was  felt  very  severely  about  both  wrists."  This  must  be  an 
extremely  rare  expression  of  the  pain.  I  have  never  met  it,  nor  do  I 
find  it  mentioned  by  others.  It  is  clear  that  the  relations  of  brachial 
symptoms2  (neuralgia)  to  angina  pectoris  are  various.  Sometimes, 
though  infrequently,  there  are  no  pains  in  the  arms,  even  in  quite  severe 
attacks  of  angina.  Again,  the  brachial  symptoms  are  very  prominent, 
begin  the  attack  of  angina,  and  last  longer  than  it  does.  The  fact  is, 
however,  that  the  description  of  pain  and  its  radiation,  especially 
where  it  has  the  remarkable  intensity  of  that  belonging  peculiarly  to 
angina,  must  be  somewhat  inaccurate  at  times.  In  any  event,  it  could 
only  be  obtained  after  the  attack  has  passed,  and  I  am  inclined  to 
believe  that  only  exceptionally  the  patient  could  give  any  graphic  and 
truthful  description  of  it.  What  is  literally  true  is  that  the  patient 
has  the  impression  vividly  marked  of  impending  dissolution,  and  it  is 
this  sense,  together  with  the  character,  site,  and  evident  intensity  of  the 
pain,  which  are  almost  pathognomonic  of  angina. 

I  know  of  few  things  more  remarkable  in  descriptive  medicine  than 
the  account  given  in  the  life  of  Dwight  L.  Moody  by  his  son,  of  the 
anginoid  attack  near  the  close  of  the  life  of  the  great  evangelist.  In 
this  case  there  was  no  terror  or  mental  distress,  as  I  believe,  because  his 
faith  and  works  fixed  him,  as  it  were,  on  a  rock.  But  in  very  many 
instances  there  is  unquestionably  great  terror  and  mental  distress. 
This  is  pictured  often  in  the  countenance  which  has  that  gray,  ghastly, 
drawn  look  which  once  seen  leaves  an  indelible  impression  upon  the 
observers  who  may  be  near.  The  different  radiations  of  the  pain  in 
angina  are,  no  doubt,  reasonably  explained  by  the  position  of  the  car- 
diac plexus.  The  site  of  this  plexus  near  the  heart  would  serve  to 
strengthen  this  view.  In  addition,  we  have  its  divisions  and  communi- 
cations which  appear  to  justify  this  interpretation. 

According  to  one  eminent  observer,  the  pain  originates  probably  in 
the  central  nervous  system.  This  writer  also  explains  its  radiation  and 
extension  by  affirming  that  it  proceeds  from  the  spinal  cord.  One 
thing  is  pretty  certain,  if  we  may  judge  by  the  few  thorough  observations 
we  have  recorded  of  these  cases,  and  it  is  that  there  is  no  pressure  out- 
side of  the  heart  on  the  plexus  from  any  form  of  aneurism  or  other 
kind  of  tumor.  While  the  heart  may  or  may  not  be  enlarged  accord- 
ing to  circumstances,  this  enlargement,  even  though  present,  does  not 
explain  rationally  the  anginoid  symptoms. 

Cardiac  hypertrophy  and  cardiac  dilatation  are  very  frequently  met 

1  "Angina  Pectoris  and  Allied  States,"  p.  42. 
1  Boston  Med.  and  Surg.  Journ.,  March  14,  ]901,  pp.  256,  257. 
9 


122  ANGINA    PECTORIS. 

with,  and  yet  in  the  vast  majority  of  these  cases  there  are  no  anginoid 
symptoms,  properly  speaking.  Leaving  aside  these  instances,  there  are 
a  few  where  the  heart  is  seemingly  of  normal  size  and  volume,  and  we 
must,  therefore,  seek  an  explanation  of  anginoid  pains  in  some  other 
direction.  Even  in  acute  cardiac  dilatation,  no  intense  pain  is  felt, 
and  yet  we  should  have  in  just  such  cases  pressure  on  or  distention  of 
nervous  fibres  under  the  endocardium.  Moreover,  this  pressure  or  dis- 
tention must  be  very  much  greater  in  patients  thus  affected  than  in 
those  suffering  with  angina  where  no  similar  condition  exists.  During 
the  attack  the  patient  is  usually  very  pale,  and  the  pallor  has  a  certain 
gray,  ashy  hue  which  is  indicative  of  the  serious  condition  which  occa- 
sions it.  Together  with  this  pallor  there  is  extreme  weakness,  and  a 
faint  feeling,  which  cannot  be  resisted,  overwhelms  the  individual  wha 
is  attacked.  The  pulse  shows  by  its  character,  oftentimes  upon  what 
this  weakness  in  part  depends.  It  is  frequently  small,  feeble,  irregular, 
as  though  the  poorly  acting  heart  could  not  send  the  blood  to  the 
extremities.  Again,  singular' to  say,  it  is  almost  unchanged,  at  least  so 
far  as  we  can  appreciate  by  our  tactile  sensations.  In  the  former 
instance,  it  is  probable  that  there  is  present  a  spasmodic  contraction  of 
the  peripheral  arteries;  in  the  latter,  we  must  assume  that  no' such 
spasm  exists,  or,  indeed,  that  arterial  changes  are  so  advanced  that  no 
marked  impression  is  made  upon  their  contractibility  even  by  the  most 
intense  pain  and  disturbance  of  the  central  organ  of  circulation. 

Frequently  an  attack  of  angina  terminates  by  the  sudden  explosion  of 
gas  from  the  stomach.  Hence  it  is  often  stated  and  familiarly  accepted 
that  flatulent  dyspepsia  is  an  immediate  and  efficient  cause  of  a  true 
attack  of  angina.  In  my  experience  this  is  scarcely  true,  and  I  am 
more  inclined  to  the  belief  that  it  is  especially  in  cases  of  pseudo-angina, 
that  we  should  expect  to  find  symptoms  of  stomachal  weakness  or 
intolerance.  While  admitting  this,  we  should  also  not  completely 
ignore  the  fact  that  the  stomachal  conditions  which  occasion  flatulence 
may  at  times  appear  to  be  of  considerable  importance,  taken  with  other 
exciting  factors,  in  bringing  on  an  attack.  There  may  be,  as  Broad- 
bent  points  out,  a  certain  sympathetic  relationship  between  the  terminal 
fibres  of  the  vagi  in  the  stomach  and  those  in  the  heart.  Many  facts 
would  serve  to  demonstrate  this  possibility.  Certainly,  even  in  cases  of 
marked  cardiac  weakness,  where  there  has  never  been  a  true  anginoid 
attack,  dyspepsia  of  an  acute  and  very  distressing  type  will  frequently 
follow  undue  fatigue  of  any  sort  or  any  severe  shock  to  the  nervous 
system  such  as  distressing  or  alarming  news  may  readily  excite. 

A  phenomenon  which  is  somewhat  curious  is  the  fact  of  an  intense 
desire  to  urinate  during  the  period  of  an  attack,  even  though  the  effort 
is  vain,  simply  because  the  bladder  is  frequently  entirely  empty. 
This  statement  may  not  invariably  be  true.     I  have  known  many  a 


ANGINA    PECTORIS.  123 

time  emotional  excitement  to  prevent  absolutely  for  a  while  the  con- 
tractile power  of  the  bladder  being  exerted,  and  where,  as  was  proven 
later,  the  bladder  contained  a  considerable  quantity  of  urine.  It 
requires  a  very  slight  degree  of  annoyance  or  mental  disturbance  in 
men  past  middle  life  to  prevent  frequently  their  power  to  void  their 
urine.  Of  course,  the  contrary  of  this  is  true,  especially  among  women 
of  a  neurotic  type,  and  who  are  still  relatively  young.  The  quality  of 
urine  of  low  specific  gravity  passed  by  them  at  times,  in  a  very  brief 
period,  is  often  very  great.  In  the  differential  diagnosis  of  true  angina 
with  pseudo-angina  this  point  should  be  borne  in  mind.  During  the 
attack  where  it  is  severe,  perspiration  will  flow  almost  constantly  from 
the  patient.  His  face  and  neck  and  hands  may  be  covered  with  it.  It 
is  cold  and  clammy,  and  lends  additional  significance  to  the  gravity  of 
the  other  symptoms. 

The  time  during  which  an  attack  lasts  is  very  variable.  Sometimes 
it  is  over  after  a  few  seconds,  although  during  this  short  period  the 
agony  is  fearful.  Again,  the  attack  is  prolonged  for  several  minutes. 
Some  authors  state  that  the  attack  may  occasionally  last  throughout  an 
entire  night,  and  that  during  all  this  time  the  patient  is  unable  to  move 
at  all  on  account  of  the  intense  pain,  and,  moreover,  is  perspiring  pro- 
fusely the  entire  period.  I  must  confess  that  I  have  never  seen  any 
attack  of  this  sort,  and  am  inclined  to  consider  them  very  infrequent. 

It  is  highly  probable,  moreover,  that  in  a  case  of  true  angina  depend- 
ing upon  advanced  degeneration  of  the  coronary  circulation,  which 
would  probably  be  present  under  such  circumstances,  the  intense  pain 
of  anginoid  character  would  terminate  life  more  rapidly.  Here,  again, 
I  should  be  disposed  to  hold  the  view  that  a  neurasthenic  or  hysterical 
element  was  present,  which  gave  strength  and  exactness  to  the  true 
diagnosis,  viz.,  pseudo-angina. 

It  must  be  admitted,  of  course,  that  there  are  instances  in  which  the 
attacks  are  certainly  anginoid  in  character,  although  they  do  not  reach 
their  complete  development.  This  fact  may  be  explained  by  stating 
that  the  patient,  having  suffered  from  attacks  previously,  so  soon  as  he 
fully  appreciates  that  one  is  coming  on  simply  stops  still  and  avoids  all 
possible  exertion  until  the  attack  has  completely  passed  away.  In  these 
examples  there  may  be  pain  in  the  chest,  but  without  radiations  toward 
the  arms  or  fingers.  Of  course,  if  the  pain  is  diminished  in  violence, 
there  is  less  dread  attached  to  the  seizures,  and  the  patient  does  not 
expect  to  die  at  any  moment.  Broadbent  and  others  speak  of  anginoid 
attacks  sine  dolore.  In  some  instances  the  chief  danger  arises  from  a 
syncopal  attack  in  which  a  patient  may  suddenly  expire.  It  may  be 
that  these  attacks  had  been  originally  painful,  and  it  was  only  subse- 
quently that  they  lost  this  characteristic  feature  entirely.  I  should 
expect,  in  such  an  instance,  to  find  at  the  autopsy  either  marked  fatty 


124  ANGINA    PECTORIS. 

degeneration  of  the  heart  walls  independent  of  coronary  changes,  or  else 
advanced  aortic  regurgitation.  Wherever  the  coronary  circulation  is 
suddenly  obstructed  with  an  embolus  or  thrombus,  the  breast  pang 
seems  to  be  almost  an  invariable  accompaniment.  In  those  cases  where 
the  attack  has  evidently  been  brought  on  by  exposure  or  exertion,  it 
does  not  usually  last  long,  and  when  the  accidental  occasion  of  the 
attack  has  disappeared,  the  seizure  itself  is  apt  to  dissipate  itself  rapidly. 
Wherever  the  attack  comes  on  spontaneously,  as  it  were,  without  any 
accidental  efficient  cause  being  evident,  it  is  apt  to  last  a  longer  time, 
and  only  to  pass  away  little  by  little  and  slowly.  Occasionally  these 
attacks  are  the  most  alarming  in  reality,  and  herald  a  fatal  termination 
in  the  not  distant  future. 

Among  the  causes  which  act  efficiently  in  bringing  on  an  attack  of 
angina  are  primarily  exertion.  We  are  apt  to  say  over-exertion  when 
the  attack  has  taken  place.  This  over-exertion  may  be  a  brisk,  rapid 
walk,  or  the  patient  may  be  walking  leisurely  and  without  effort  when 
the  seizure  occurs.  Usually,  however,  it  is  when  a  walk  has  been  pro- 
longed and  there  is  already  a  feeling  of  fatigue  that  the  angina  is  felt. 
It  has  been  noticed  that  whenever  exertion  takes  place  soon  after  a 
meal  an  attack  is  more  apt  to  occur.  It  may  be  because  digestion,  if 
slow  and  torpid,  is  thus  interfered  with,  and  gases  which  are  generated 
and  accumulate  in  the  stomach  press  against  the  diaphragm  and  indi- 
rectly against  the  heart,  and  thus,  by  causing  some  displacement  of  this 
organ,  may  occasion  notable  interference  with  the  circulation. 

One  reason,  no  doubt,  why  attacks  occur  at  times  during  sleep,  is 

because  flatus  is  prone  to  accumulate  in  the  stomach   and  intestines 

during  sleep,  and  considering  this  together  with  the  fact  that  in  the 

horizontal  position  we  have  more  pressure  of  the  abdominal  viscera 

upward,  we  realize  readily  conditions  which  are  powerful  in   causing 

distress. 

The  liability,  under  these   circumstances,  to  an  attack  is  increased 

notably  by  a  feeble  circulation.  Moreover,  as  we  know,  the  circula- 
tion is  always  less  active  in  repose,  and  this  state  is  what  prevails 
during  sleep.  A  loaded  rectum  is,  also,  a  condition  to  be  avoided,  and 
anyone  subject  to  constipation  must  see  to  it  that  the  bowels  are  properly 
evacuated.  The  distended  bowel  may  perhaps  act  in  a  reflex  manner, 
as  well  as  by  direct  pressure. 

The  influence  of  cold  is  sometimes  very  evident.  This  is  particularly 
true  when  a  patient  is  walking  against  a  cold  wind.  Nothing  more  is 
required  than  this  sometimes  to  precipitate  an  attack.  On  the  other 
hand,  mild,  warm  weather  is  conducive  to  well-being,  and  sufferers 
from  angina  will  often  escape  attacks  during  long  periods  when  the 
weather  is  free  from  rapid  changes  and  remains  relatively  balmy.  It 
is  essential  at  night  for  a  patient  to  see  that  the  bed  is.  comfortably 


ANGINA     PECTORIS.  125 

warm  and  that  no  chilling  of  the  surface  ensues;  otherwise,  an  attack 
will  often  follow.  This  precaution  may  be  readily  attended  to  with  a 
hot-water  bottle  or  heated  bricks.  Gentle  friction  of  the  surface  of  the 
body,  perhaps,  before  the  patient  retires,  is  also  a  proper  precaution  to 
take.  The  wearing  of  long  woollen  stockings,  and  particularly  those 
which  are  somewhat  loosely  knit  and  allow  free  transpiration,  is  espe- 
cially desirable,  so  as  to  keep  the  extremities  suitably  warm.  I  know 
of  no  small  detail  so  important  as  this  in  all  affections  in  which  the  cir- 
culation is  notably  impaired,  and,  of  course,  it  becomes  doubly  impera- 
tive in  warding  off  painful  attacks  which  are  too  frequently  occasioned 
by  local  chilling  of  the  feet. 

In  view  of  the  fact  that  dyspepsia  is  such  a  frequent  symptom  of 
angina,  and  appears  as  an  efficient  cause,  in  the  judgment  of  a  few 
writers,  quite  as  often  as  an  effect,  it  is  important  to  avoid  all  late  or 
too  abundant  dinners.  The  food  at  this  meal  should  be  of  the  simplest 
kind,  and  no  overloading  of  the  stomach  should  be  permitted.  In  a 
similar  way,  no  sauces,  condiments,  or  insufficiently  cooked  food  should 
be  tolerated. 

Whenever  an  attack  has  occurred,  it  behooves  the  patient  to  be  more 
than  usually  circumspect  in  all  his  doings,  not  to  bring  on  another  one. 
This  is  especially  true  of  any  exertion  which  seemingly  has  been  the 
direct  cause  of  an  outbreak.  And  yet  this  counsel  is  sometimes  almost 
unnecessary,  because  the  patient's  own  feebleness,  which  follows  a  pri- 
mary attack,  will  compel  him  almost  to  walk  very  slowly  and  deliber- 
ately, even  if  he  walks  at  all,  for  some  hours  or  days  subsequently. 
No  doubt  these  anginoid  attacks  would  not  occur  if  the  heart  had  suffi- 
cient reserve  force  to  respond  adequately  to  the  call  made  upon  it. 
Unfortunately,  it  has  not,  and  it  is  therefore  evident,  in  many  instances, 
that  the  attack  is  directly  occasioned  when  we  reach  final  causes,  by  the 
manifest  inability  of  the  heart  to  respond  to  the  call  made  upon  it  for 
increased  vigor. 

Angina  pectoris  is  not  necessarily  connected  with  any  special  lesion. 
Practically,  it  is  almost  unknown  to  have  either  stenosis  or  incompe- 
tence of  the  mitral  valve  appear  as  a  direct,  efficient  cause  of  it.  It  is 
true,  however,  when  there  have  been  several  attacks  of  angina,  it  is 
not  infrequent  to  observe  mitral  incompetence  arise  subsequently.  In 
some  of  these  instances  it  has  been  noted,  where  aortic  incompetence 
already  existed,  that  this  affection  was  ameliorated  as  regards  its  symp- 
toms, and  that  the  anginoid  attacks  also  became  less  severe.  The 
explanation  appears  to  be  in  the  lessened  blood  pressure  thus  brought 
about,  as  shown  in  the  arterial  pulse  and  in  the  diminished  accentuation 
of  the  aortic  second  sound.     Musser1  has  insisted  upon  the  importance 

'  Transactions  of  tbe  Association  of  American  Physicians,  vol.  x.  p.  85. 


126  ANGINA    PECTORIS. 

of  this  finding,  and  has  reported  several  examples  in  his  own  experience. 
Broadbent1  has  also  specially  emphasized  similar  instances. 

Angina  is  frequently  connected  with  fibrous  myocarditis,  and  at  the 
autopsy  such  organic  change  in  the  heart  muscle  is  apt  to  be  found. 
So  usual  is  this  condition  that  Gibson  states  it  is  almost  a  surprise  not 
to  find  it.  When  fibrous  myocarditis  is  noted,  it  is  frequently  accom- 
panied with  evidences  of  arterial  degeneration.  The  coronary  arteries 
are  usually  implicated.  Especially  is  this  true  where  aortitis  is  present. 
The  lesion  may  be  limited  to  their  origin,  which  is  sometimes  narrowed 
and  thickened.  The  arteries  may  also  be  affected  in  a  considerable 
extent,  and  the  organic  changes  may  be  considerably  advanced.  Occa- 
sionally they  have  merely  lost  elasticity  ;  in  more  pronounced  alteration 
they  may  have  become  markedly  atheromatous,  or,  indeed,  calcified. 

According  to  Douglas  Powell,  fatty  degeneration  of  the  heart  walls 
often  exists.  Sometimes,  indeed,  the  heart  is  so  much  degenerated  that 
it  is  easily  torn,  and  the  finger  sinks  into  it  on  slight  pressure.  Some- 
times, to  the  naked  eye,  the  fat  exists  only  in  patches,  affecting  merely 
the  papillary  muscles  or  different  areas  of  the  ventricles.  Even  in  these 
instances,  however,  if  we  make  use  of  the  microscope,  we  are  apt  to  find 
considerable  degeneration  of  the  walls,  where  there  has  been  no  real 
change  of  coloration.  In  a  few  instances  the  microscope  shows  almost 
complete  disappearance  of  the  muscular  fibres. 

As  a  concurrent  condition  with  fatty  degeneration,  we  discover  more 
or  less  advanced  changes  of  the  coronary  arteries,  very  similar  to  those 
already  mentioned  in  connection  with  fibrous  myocarditis.  These  evi- 
dences of  fatty  degeneration  are  particularly  found,  of  course,  where 
the  fatal  termination  appears  to  be  intimately  dependent  upon  the  pre- 
vious anginoid  attack.  It  should  be  remarked  in  this  place  that  we 
often  have  both  anterior  conditions,  viz.,  that  of  fibrous  myocarditis  or 
of  fatty  degeneration,  without  having  attacks  of  true  angina.  Accord- 
ing to  Gibson,  the  relations  of  angina  with  endocardial  lesions  is 
not  so  distinct.  It  is  true,  of  course,  that  degeneration  of  cardiac 
walls  may  often  cause  it,  and,  therefore,  it  is  frequently  found  at  the 
autopsy.  The  earlier  writers,  like  Morgagui,  certainly  attached  angina 
directly  to  the  existence  of  aortic  disease,  and  in  one  of  Heberden's 
cases,  where  the  autopsy  was  made  by  John  Hunter,  this  affection  is 
duly  recorded.  On  the  other  hand,  we  know  that  the  most  advanced 
changes  with  ossification  may  exist  at  the  aortic  orifice,  and  yet  there 
may  be  present  during  life  no  morbid  symptoms  at  all.2  These  instances 
must  be  somewhat  exceptional.  What  is  true  is,  where  aortic  lesions  have 
been  proven  at  autopsy,  often  pain  has  been  noted  prior  to  death.     No 

1  British  Medical  Journal,  1891,  vol.  i.  p.  747.    Quoted  by  Osier. 

2  Sernple,  p.  104  et  seq. 


ANGINA    PECTORIS.  127 

doubt,  this  pain  has  been  in  part  due,  at  least,  to  interference  with  the 
coronary  circulation,  caused  by  accompanying  aortitis,  with  which  there 
may  also  be  a  certain  degree  of  dilatation,  or,  indeed,  a  sacculated 
aneurism.  Arterial  degeneration,  especially  arterio-sclerosis,  is  often 
adjoined  to  attacks  of  angina.  Where  the  coronary  arteries  are  degen- 
erated, and  where  the  angina  is  seemingly  dependent  upon  this  condi- 
tion, we  should  not  lose  sight  of  the  fact  that  the  other  arteries,  being 
degenerated,  are  also  doubtless  contributory.  The  affection  of  the 
coronary  arteries  through  sclerosis  and  consequent  narrowness,  prevents 
a  sufficient  blood  supply  reaching  the  heart,  and  hence  interferes  with 
its  nutrition.  A  thrombus  or  embolus  may  obstruct  the  vessels,  but  it 
is  doubtful  whether  one  or  the  other  of  these  conditions  causes  angina. 
(Gibson.)  One  thing  is  sure,  viz.,  we  often  find  calcification  of  these 
arteries  without  previous  anginal  attacks.  Adherent  pericardium  may 
be  found,  but  does  not  occasion  anginal  attacks  unless  accompanied  by 
a  lesion  at  the  aortic  orifice, 

Angina  has  been  observed  following  injuries  to  the  chest  walls.  In 
these  cases  the  aorta  may  have  been  affected.  Broad  bent  states  its 
presence  occasionally  in  malarial  fever.  It  may  also  be  present  in 
advanced  diabetes  where  the  arteries  may  become  thickened,  thus  giv- 
ing rise  to  increased  tension,  and  followed  by  attacks  of  true  angina. 
It  is  not  infrequent  to  find  anginoid  attacks  occasioned  evidently  by 
the  presence  of  the  gouty  poison.  In  these  cases  the  prognosis  is 
only  serious  where  the  intracardiac  changes  are  already  advanced,  as 
shown  by  the  weakness  and  irregularity  of  the  heart's  pulsations.  In 
some  of  these  cases  we  find  notably  fibroid  myocardial  changes  in 
patches  or  disseminated.  Even  in  these  instances,  prior  to  death,  there 
may  have  been  a  few  or  no  threatening  cardiac  symptoms.  In  a  few 
rare  cases  neuritis  of  the  cardiac  plexus  and  also  of  the  phrenic  nerve 
has  been  noted  (Lancereaux,  Peter)  where  anginoid  attacks  have 
occurred.  The  view  of  Semple  is,  indeed,  that  angina  considered  as  an 
idiopathic  disease  is  connected  with  an  affection  of  the  pneumogastric 
or  phrenic  nerve.  Of  course,  it  is  difficult  always  to  pronounce  what 
the  precise  structural  changes  are.  Still,  they  are  doubtless  present, 
and  later  will  be  discovered.  Meanwhile  we  are  forced  to  rank  a  few 
such  instances  among  the  "  neuroses."  Frequently,  doubtless  angina 
is  associated  with  minute  structural  changes  which  only  subsequent 
close  investigation  will  determine  Flint  is  evidently  of  the  opinion 
that  the  connection  between  angina  and  organic  lesions  of  the  heart  is 
rare.  Thus  he  has  only  observed  fifteen  cases  in  388  cases  of  the  latter. 
Again,  Flint  says  that  in  ten  years  he  has  noted  only  four  cases  of  true 
angina,  that  is  to  say,  where  the  disease  was  unconnected  with  cardiac  or 
aortic  lesions.  It  is  clear  that  in  all  instances  where  there  is  present  an 
organic  lesion  of  the  heart  or  arteries,  whatever  suffering,  if  any,  the 


128  ANGINA    PECTORIS. 

patient  may  experience  should  be  directly  explained  by  them.  This 
leads  to  the  conviction  that  only  those  cases  in  which  no  such  lesion  is 
discoverable  should  be  ranked  among  the  true  cases  of  angina.  As  a 
rule,  when  sudden  deaths  occur  in  what  has  been  called  angina, 
pathological  lesions  sufficiently  explanatory  are  found  at  the  autopsy. 

The  condition  of  the  heart  during  an  attack  of  angina  has  been 
believed  to  be  one  of  spasm.  At  least,  this  is  the  opinion  of  some 
writers.  It  is  certainly  true  of  Heberden,  who  first  so  accurately  de- 
scribed these  attacks  in  his  commentaries.  This  does  not  seem  to  be 
altogether  a  tenable  opinion,  if  one  has  regard  to  the  fact  that  the  heart 
has  rarely  been  found  thus  contracted. 

Usually  the  heart  stops  in  diastole,  and  is  found  after  death  in  a 
relaxed  condition.  Again,  during  life,  while  the  pulse  at  the  wrist  is 
sometimes  irregular  and  weak,  it  never  disappears  entirely,  which  it 
certainly  would  if  the  heart  were  in  a  state  of  forcible,  spasmodic  con- 
traction. 

It  has  been  supposed  that  the  heart  during  an  attack  presented  a 
sort  of  hour-glass  contraction  not  dissimilar  to  that  of  the  uterus.  This 
may  be,  and  yet  it  would  be  difficult  to  prove.  Broadbent  confesses  in 
this  connection  that  he  has  a  very  imperfect  notion  of  what  the  condi- 
tion of  the  heart  really  is  during  an  attack.  The  evident  fact  is  that 
during  a  paroxysm  of  angina  stress  is  put  upon  the  heart  to  which  it  is 
quite  unequal  to  respond,  and  thus  it  shows  its  considerable  lack  of 
power.  Often  the  stress  put  upon  the  heart  is  due  to  the  continuous 
high  tension  of  the  peripheral  arteries.  Occasionally,  however,  there 
is  low  tension  in  the  peripheral  circulation,  and  in  these  instances,  if 
there  occur  a  sudden  general  arterial  spasm,  the  amount  of  work  thrown 
upon  the  heart  becomes  rapidly  much  greater,  and  consequently  the 
heart  shows  relatively  greater  distress  than  where  the  peripheral  resist- 
ance is  continuously  high  and  exaggerated.  In  those  cases  where  there 
is  marked  and  continuous  high  tension  in  the  peripheral  arteries  we 
might  suppose  that  pain  in  angina  was  explained  by  greater  pressure 
thrown  upon  the  heart.  This  can  scarcely  be  true  when  we  consider 
how  many  such  cases  escape  any  such  pain.  Again,  in  acute  dilatation 
of  the  ventricles,  we  have  great  pressure  brought  upon  the  heart  walls, 
and  yet  no  pain  results.  Neuralgic  predisposition  is  occasionally  given 
as  an  explanatory  cause.  This  is  scarcely  true  if  we  mean  by  that  an 
acquired  or  evident  neurotic  tendency,  since  this  disease  occurs  more  fre- 
quently with  men  than  with  women.  It  would  seem  as  though  from  the 
fact  that  when  the  attack  occurs  immediately,  the  patient  stops  doing 
anything  he  is  occupied  with,  or  exercising,  if  that  be  what  he  is  about, 
that  there  is  a  certain  pre- ordered  protective  arrangement  internally 
to  guard  against  these  outward  manifestations  of  man's  life.  (Broad- 
bent.) 


ANGINA    PECTORIS.  129 

Pain,  according  to  Bramwell,1  is  due  to  irritation  of  the  nerve  ter- 
minations in  the  walls  of  the  heart  itself.  He  admits,  however,  that 
the  theory  of  irritation  due  to  spasmodic  contraction  is  plausible,  and 
compares  this  opinion  with  what  occurs  in  the  calf  muscles,  spasmodi- 
cally contracted,  in  ordinary  cramp. 

Attacks  of  false  angina  often  resemble  those  of  the  real  kind.  Some- 
times the  description  of  the  attack  by  friends  will  enable  us  to  reach  a 
correct  diagnosis.  If  the  patient  becomes  pale,  anxious,  and  shows 
signs  of  great  distress,  it  may  not  of  necessity  be  true  angina.  If,  on 
the  contrary,  there  be  no  such  changes  evident,  we  can  be  very  sure 
that  it  is  only  an  attack  of  pseudo-angina.  There  is  much  unreliability 
in  the  patient's  accounts,  mainly  because  they  are  apt  to  read  up  about 
these  attacks,  and  often  give  an  exaggerated  idea  of  their  own  sensa- 
tions. Age  will  throw  some  light  upon  the  diagnosis.  Under  forty 
years  of  age  in  the  male,  angina  occurs  very  rarely,  unless  there  be  a 
pronounced  lesion  at  the  aortic  orifice  or  aortitis.  In  females  it  is  rare 
at  any  age,  although  attacks  of  pseudo-angina  are  not  infrequent  with 
them,  especially  those  of  an  undoubted  neurotic  temperament.  Heber- 
den,  for  example,  in  speaking  of  the  cases  observed  by  him,  being  in 
number  over  100,  states  that  three  occurred  in  women,  one  in  a  boy 
twelve  years  of  age,  and  the  others  in  men  near  or  over  fifty  years. 

Usually  the  first  attacks  of  angina  occur  during  physical  exertion. 
Later  on  they  may  come  on  severely  and  more  readily,  and  then  we 
may  make  the  diagnosis  surely,  even  though  the  determining  cause  is 
slight.  The  physical  examination  will  reveal,  in  case  of  true-angina,  the 
changes  mentioned  in  the  aorta  or  at  aortic  orifice.  Where  the  attack 
at  first  comes  on  without  exertion  and  at  a  fixed  period  after  ingestion 
of  food,  it  would  seem  to  be  of  digestive  provenance  or  pseudo-angina, 
and  ordinarily  due  to  a  dyspeptic  attack.  Unless  history,  nature,  and 
onset  of  attack  all  concur  together  with  physical  signs  to  establish  diag- 
nosis of  true  angina,  we  should  lean  strongly  to  diagnosis  of  pseudo- 
angina,  and  almost  invariably,  if  we  can  discover  any  facts  to  support 
this  diagnosis.  If  we  leave  out  attacks  of  pseudo-angina  which  are 
evidently  neurotic  or  of  hysterical  nature,  we  can  usually  find  in  some 
digestive  disorder,  particularly  of  the  stomach,  a  sufficient  explanation 
of  them.  There  are  eructation,  marked  flatulence,  pain,  occasional 
attacks  of  nausea,  or  vomiting,  which  all  point  in  this  direction.  A 
combination  sometimes  found  is  that  of  dilatation  of  the  stomach,  with 
high  arterial  tension.  If  the  heart  be  affected  in  these  cases  and  they 
are  improperly  treated,  a  fatal  result  may  not  infrequently  follow.  If, 
for  example,  digitalis  or  nitroglycerin  be  alone  used,  or  the  Schott 
treatment  advised  and  carried  out  without  any  care  of  the  stomach,  and 

1  Diseases  of  the  Heart,  p.  676. 


130  ANGINA    PECTORIS. 

especially  if  the  subject  be  old,  such  a  denouement  may  not  be  a 
surprise. 

The  prognosis  of  true  angina  is  often  uncertain ;  and  yet  we  have 
certain  conditions  which  guide  us  to  make  it  correct.  We  should 
estimate  carefully  the  relative  predominance  of  the  two  factors  often 
producing  it — on  the  one  hand,  degenerated  heart  walls,  on  the  other, 
vascular  changes.  If  there  be  high  arterial  tension  present,  and  if  at 
the  same  time  the  heart  action  is  forcible  and  the  aortic  second  sound 
marked,  we  may  hope  by  proper  treatment  to  modify  these  conditions 
for  a  while  with  the  use  especially  of  nitroglycerin  and  the  nitrites. 
Again,  if  over-exertion  and  excitement  bring  on  the  attacks,  or  if  flatu- 
lent dyspepsia  be  a  decided  and  powerful  influence  in  producing  them, 
we  should  hope  to  avoid  with  care  and  treatment  their  natural  outcome. 

On  no  account  should  the  patient  walk  hurriedly,  especially  in  going 
up  hill.  He  should  also  never  take  even  a  moderate  walk  until  a 
certain  time  had  elapsed  after  his  last  repast. 

Attacks  of  angina  which  accompany  aortic  disease  may  last  a  con- 
siderable time  without  bringing  on  a  fatal  result  if  carefully  watched 
and  guarded.  The  worst  cases  are  those  which  recur  in  the  night  or  at 
times  where  no  accidental  cause  is  present  and  avoidable  which  occa- 
sions them.  Again,  if  examination  is  relatively  negative,  if  the  heart  is 
of  normal  size,  without  manifest  lesion  of  any  kind,  and  yet  its  action 
is  feeble,  its  impulse  scarcely  felt,  and  the  pulse  usually,  if  not  invari- 
ably, of  low  tension,  these  give  great  anxiety  by  reason  of  the  vagueness 
and  uncertainty  as  to  the  conditions  which  may  be  present  and  at  any 
time  become  imminently  threatening. 

The  apparent  severity  of  two  attacks  may  be  similar,  and  yet  the 
relative  danger  of  them  may  be  absolutely  different.  It  is  difficult, 
therefore,  at  times  to  make  anything  like  a  sure  forecast.  Of  course, 
where  there  are  pronounced  cardiac  and  arterial  changes,  and  where, 
in  addition,  heart  failure  has  followed  hypertrophy,  the  outlook  is 
assuredly  very  grave  indeed.  If,  at  the  same  time,  aortic  regurgitation 
also  be  present  the  prognosis  becomes  even  more  serious.  In  a  similar 
way,  if  chronic  renal  changes  exist  the  future  of  the  patient  must 
appear  dark  and  imminent.  Gibson  states  that  the  prognosis  of  those 
affected  with  fatty  degeneration  is  far  less  serious  than  the  preceding. 
Provided  always  the  external  and  avoidable  causes  of  aggravation  are 
prevented,  such  patients  may  often  live  many  years.  Of  course,  toxic 
angina  is  far  less  grave.  As  a  rule,  with  the  removal  of  the  cause  the 
case  becomes  curable.  In  neurotic  cases,  while  we  should  expect  fre- 
quent recurrences  of  the  paroxysms,  it  is  wholly  improbable  to  have  a 
fatal  termination. 

In  this  catagory  may  be  placed  frequently  the  so-called  idiopathic 
cases.     They  are  often  extremely  painful,  but  as  no  incurable  lesions 


ANGINA    PECTORIS.  131 

exist,  they  tend  to  improvement  or  recovery  if  properly  managed.  Of 
course,  we  should  be  careful  in  making  even  in  these  cases  too  favorable 
a  prognosis,  since  there  may  be  some  underlying  structural  change  of 
the  heart  walls  or  coronary  arteries  which,  during  life,  could  not  be 
determined.  There  are  unquestionably,  according  to  Semple,  cer- 
tain cases  of  pure  angina  in  which  the  autopsy  reveals  no  organic 
changes. 

The  treatment  of  angina  depends  upon  what  is  the  apparent  or 
obvious  cause.  In  many  instances,  owing  to  the  difficulty  of  tracing 
accurately  to  what  the  attack  is  primarily  due,  our  treatment  must  be 
essentially  empirical.  First  of  all,  we  must  consider  the  general  health, 
and  from  this  point  of  view  our  treatment  should  be  hygienic.  The 
means  at  our  command  are  here  what  pertain  to  air  and  light,  rest  and 
exercise,  food  and  drink.  After  these  have  all  been  inquired  into  and 
regulated,  as  far  as  may  be,  we'  naturally  seek  for  the  proper  medicinal 
remedies  to  meet  the  indications  of  each  special  case.  In  general,  also, 
the  efficiency  of  our  treatment  will  depend  much  to  what  degree  we  may 
be  able  to  relieve  peripheral  resistance  to  a  heart  frequently  weakened. 
If,  perchance,  we  find  between  the  regular  pulse  beats  evidence  of 
increased  tension  to  our  tactile  sensations,  we  may  often  reduce  this  by 
appropriate  remedies.  Still,  in  order  to  recognize  it,  we  must  at  times 
examine  the  heart  and  arteries  at  different  periods,  before  and  after 
exertion.  Not  infrequently  the  arteries  are  notably  degenerated,  hard, 
thickened,  tortuous,  and  even  calcareous.  We  can  then  do  little  to 
affect  them  directly.  Yet,  the  capillary  system,  in  which  there  may  be 
notable  resistance  without  excessive  changes,  and  which  has  caused  in 
a  measure  the  arterial  and  cardiac  changes,  may  be  still  favorably 
influenced  by  appropriate  drugs,  and  account  should  be  kept  of  this 
fact.  In  gouty  conditions  the  peripheral  circulation  may  show  increased 
tension,  although  not  visibly  degenerated,  and  this  condition,  of  course, 
may  be  favorably  influenced  by  appropriate  medication. 

In  these  latter  cases  the  ordinary  treatment  with  a  mercurial,  fol- 
lowed by  a  saline,  once  or  twice  a  week,  will  lower  arterial  pressure. 
Between  times  the  use  for  a  while  continuously  of  iodide  of  potash  and 
colchicum  may  be  of  signal  benefit.  The  employment  of  bitter  tonics, 
if  the  indication  presents,  and  the  proper  regulation  of  the  diet  is, 
of  course,  useful.  According  to  Powell,  hop,  columba,  and  chiretta  are 
better  tonics  in  these  cases  than  quinine  and  strychnine.  In  the  "  neu- 
ralgic bouts,"  to  which  they  are  prone,  he  praises  quinine  and  phen- 
acetin.  Where  angina  occurs  with  marked  aortic  disease  it  is  difficult 
sometimes  to  know  to  what  extent  we  may  be  able  to  help  the  attacks 
by  reducing  tension  of  the  pulse.  Where  the  pulse  remains  feeble 
between  the  attacks,  and  the  heart  has  a  weak  impulse,  we  should  care- 
fully endeavor  to  help  with  cardiac  tonics,  but  frequently  we  can  be  of 


132  ANGINA    PECTORIS. 

little  real  service  in  view  of  the  pronounced  degenerative  changes 
present  in  the  heart  and  arteries.  Occasionally  arsenic,  combined  with 
iodide  of  potassium  and  nux  vomica,  is  useful  where  the  arterial  tension 
is  not  too  pronounced.  Preference  may  be  given  in  many  instances  to* 
the  sodium  salt  of  the  iodide,  both  between  and  during  the  attacks. 
According  to  Schott,  it  is  less  prone  to  cause  heart  failure ;  but  even 
this  salt  is  "apt  to  destroy  the  molecules  of  albumin"  if  continued  too 
long  or  in  increasing  doses.  Milk  is  the  best  menstruum  for  either 
salt,  as  in  this  way  stomachal  intolerance  is  less  likely  to  occur.  In 
these  and  other  cases  we  should  try  to  preserve  the  use  of  the  nitrites 
and  nitroglycerin  for  the  attacks.  Formerly  the  diffusible  stimulants, 
like  brandy,  ammonia,  lavender,  camphor,  etc.,  were  much  used  for 
these  attacks.  Now  they  are  almost  abandoned  for  nitroglycerin  and 
nitrite  of  amyl.  These  latter  are  particularly  useful  in  relieving  pain, 
and  to  accomplish  it  they  dilate  peripheral  arteries.  Nitrite  of  amyl 
by  the  rapidity  of  its  action  is  preferably  employed.  Nitroglycerin 
and  the  sweet  spirits  of  nitre  produce  similar  effects  in  different  degrees. 
All  of  these  are  free  from  dangerous  effects,  as  a  rule;  not  so  of  nitrite 
of  sodium,  which  may  produce  alarming  results.  (Gibson.)  Nitrite  of 
amyl  and  nitroglycerin  dilate  arteries,  increase  frequency  of  pulse  and 
respiration,  and  reduce  irritability  of  the  nervous  system.  Where 
increased  acceleration  of  the  pulse  and  respiration  are  already  present 
the  nitrites  must  be  employed  with  great  care,  as  they  might  possibly 
cause  greater  distress.  While  they  are  said  to  be  heart  stimulants,  they 
mainly  cause  relaxation  of  the  arteries  and  also  of  the  cardiac  muscular 
fibres.    (Broadbent.1) 

The  nitrites  have  their  drawbacks  also  in  the  fact  that  patients  find 
so  much  relief  from  their  use  that  they  use  them  too  frequently  and 
injudiciously.  A  word  of  warning  should  be  thrown  out  because  life 
is  sometimes  shortened  by  their  inconsiderate  use.  Glycosuria  has  been 
produced  by  them,  it  is  stated.  In  many  instances  the  nitrites  are  less 
useful  than  iodide  of  potash.  Nitrite  of  amyl  may  be  carried  about 
with  one  so  as  to  be  used  immediately.  The  nitrite  of  amyl  in  glass 
globules,  of  3  to  5  minims,  may  be  in  a  silk  bag  and  broken  upon  a 
handkerchief  and  inhaled  as  required.  The  nitroglycerin  tablets,  one 
one-hundredth  of  a  grain,  may  also  be  taken  in  doses  of  one  or  two  when 
attack  occurs.  They  do  not  act  as  rapidly  as  the  nitrite  of  amyl,  but 
their  effect  is  more  prolonged,  and  on  that  account  may  be  more  valu- 
able in  certain  cases. 

Some  cases,  however,  are  not  relieved  by  nitroglycerin  tablets  and  are 
relieved  by  nitrite  of  amyl.  According  to  Broadbent,  such  cases  have 
seemed  to  him  to  originate  in  the  right  ventricle. 

1  This  opinion  about  heart  fibres  I  do  not  share  save  very  exceptionally. 


ANGINA    PECTORIS.  133 

It  is  the  belief  of  Dr.  B.  Addy1  that  we  have  in  erythrol  tetranitrate 
a  remedy  superior  even  to  "nitroglycerin,"  its  effects  being  very  rapid 
and  more  lasting.  Tablets  of  one-half  grain  each  were  given  by  him 
twice  or  three  times  a  day.  They  did  not  cause  headache,  and  the 
remedy  soon  checked  the  attacks.  It  is  true  the  patient  died  after  a 
fortnight  of  syncope,  but  during  this  period  great  relief  from  suffering 
was  experienced. 

Sometimes,  where  the  heart  is  weak  and  the  nitrites  do  not  relieve, 
although  they  may  relax  the  peripheral  circulation,  we  must  recur  to 
the  old  stimulants.  In  addition,  a  turpentine  stupe,  or  mustard  leaf,  or 
poultice  may  be  applied  over  the  chest  and  will  occasionally  afford  a 
measure  of  comfort.  Whenever  these  local  applications  fail,  great 
relief  is  obtained  from  a  hot-water  bag  at  a  temperature  of  140°  F. 
to  170°  F.,  "moved  with  light  touches  over  the  whole  chest."2  If, 
despite  all  this,  the  attack  is  prolonged  and  unrelieved,  we  must  give 
a  hypodermic  injection  of  morphine  and  atropine,  using  at  first  small 
doses,  and  later,  if  need  be,  becoming  bolder,  and  using  larger  doses. 
It  is  well  to  make  injections  deep  in  the  muscle,  where  the  circula- 
tion is  more  active  than  in  the  cellular  tissue  under  the  skin.  In 
some  instances  we  should  recur  to  chloroform  inhalations  as  being 
the  only  hope  of  relief  to  the  patient.  At  times  they  are  undoubt- 
edly dangerous,  and "  especially  is  this  believed  to  be  true  if  fatty 
heart  is  present.  As  a  matter  of  fact,  however,  fatty  heart  cannot 
always  be  diagnosed  with  accuracy.  The  apex  may  be  strong  and  the 
pulse  regular  and  good,  and  yet  fatty  heart  may  exist,  and  sudden 
death  follow.  Again,  moreover,  it  has  been  shown  that  chloroform 
may  be  given  safely  where  fatty  heart  later  is  known  to  exist  by  the 
revelations  of  the  autopsy.  We  must  relieve  intense  pain,  however, 
even  if  there  be  risk,  and  it  can  only  be  done  at  times  by  such  agents. 
(Balfour.) 

In  cases  where  there  is  marked  heart  failure,  ether  or  brandy  should 
be  employed  hypodermically  in  doses  of  gss  to  3j.  To  each  hypo- 
dermic injection  one  or  two  tablets  of  one  one-hundredth  of  a  grain  of 
nitroglycerin  may  be  added.  The  latter  should  be  employed  with 
caution,  however,  as  occasionally  considerable  soreness  and  even  ulcera- 
tion of  the  skin  may  result. 

Theodore  Schott  does  not  value  very  highly  digitalis  or  strophanthus 
in  cases  where  the  heart  requires  stimulation,  even  in  uncomplicated 
forms  of  angina  pectoris  caused  by  sclerosis  of  the  coronary  vessels. 

Oxygen  inhalations  are  often  also  useful,  not  only  to  satisfy  the  air 
hunger,  due  to  obstruction  of  circulation  in  the  lungs,  but  also  to 
stimulate  cardiac  circulation  and  help  nutrition  of  its  muscles,  and  thus 

1  British  Medical  Journal,  May  6, 1899,  p.  1089.  a  Lancet,  September  8, 1900,  p.  726. 


134  ANGINA    PECTORIS. 

get  rid  of  effete  material  which  interferes  with  proper  metabolism. 
(Powell.)  In  these  cases  the  oxygen  must  be  used  with  a  funnel  near 
the  nose  and  mouth,  so  that  it  may  be  inhaled  frequently  and  without 
effort.  As  corroborative  of  the  extreme  value  of  inhalations  of  oxygen 
in  the  treatment  of  some  severe  cases  of  angina  pectoris,  I  would  refer 
to  one  recently  reported  in  the  British  Medical  Journal  for  December  1. 
1900,  p.  1568. 

Rest  in  bed  for  a  time  is  often  desirable  after  acute  paroxysms  have 
passed,  but  later  it  is  useful,  as  far  as  possible,  to  get  the  patient  back  to 
his  ordinary  life,  with  judicious  restrictions.  The  same  rules  apply 
here,  however,  as  in  other  heart  affections.  We  must  remember,  also, 
that  exertion  which  one  day  may  seem  all  right,  another  day  may  cause 
distress  and  oppression.  This  is  one  of  the  objections  to  Oertel's  system 
of  treatment.     (Broadbent.) 

Physical  therapy  is  undoubtedly  useful  in  some  instances,  but  it 
must  be  utilized  with  great  care.  This  counsel  pertains  particularly  at 
the  present  time  to  the  treatment  as  instituted  at  Bad  Nauheim,  where 
the  resistant  movements  in  conjunction  with  carbonic  baths  are  prac- 
tised. In  advanced  arterio-sclerosis  every  increase  of  the  blood  press- 
ure which  is  the  result  of  this  treatment  might  lead  to  fatal  conse- 
quences (embolism,  apoplexy,  rupture  of  aneurism  of  heart,  or  aorta). 
"Advanced  sclerosis  is,  therefore,  a  contraindication  for  this  treat- 
ment." (Schott.)  The  value  of  many  medicaments  in  angina  comes 
from  producing  low  blood  pressure.  The  balneological  and  gymnastic 
treatment  exercises  a  tonic  influence,  and  "  by  strengthening  heart 
muscle,  as  well  as  by  acting  on  cardiac  nerves,  distressing  symptoms 
of  angina  are  either  removed  or  reduced."    (Schott.) 

Guidance  should  be  had  in  regard  to  the  bad  effects  of  winds,  great 
heat  or  cold,  or  rapid  changes.  Also,  an  atmosphere  heavily  laden 
with  moisture  is  injurious.  Internal  conditions  of  dyspepsia  and  con- 
stipation must  be  warded  against.  A  great  deal  of  tact  and  good 
judgment  are  required,  and  the  patient's  disposition  should  be  thoroughly 
known.  Rest,  particularly  after  meals,  should  be  insisted  upon,  as 
patients  are  particularly  liable  to  attacks  at  these  times. 

In  general,  supervision  and  counsel  must  be  employed  about  exercise. 
Where  an  attack  has  lately  occurred,  it  is  wisdom  to  refrain  from 
exertion  for  a  while,  especially  if  the  heart  is  weak  and  fluttering,  and 
afford  it  time  to  re-establish  itself. 


TUBERCULOUS  PERICARDITIS : 

Followed  by  Remarks  upon  Paracentesis  and  Incision. 


Two  cases  of  this  somewhat  rare  disease  have  been  under  my  care 
within  the  past  eighteen  months.  In  both  cases  autopsies  were  ob- 
tained— the  one  complete,  the  other  only  embracing  the  examination 
of  the  heart  and  pericardium.  In  one  of  these  instances  the  pericar- 
dium was  aspirated  several  times;  in  the  other  it  was  not  considered 
necessary  or  judicious  to  operate.  The  history  of  my  first  case  was 
read  at  a  meeting  of  the  Practitioners'  Society,1  October  11,  1901,  and 
the  specimen  shown.     The  case  was  discussed  by  the  members. 

During  the  past  eighteen  months  I  have  also  taken  care  of  two  other 
cases  of  pericarditis.  Of  these,  one  occurred  as  a  complication  of 
Bright's  disease  ;  the  other  apparently  of  rheumatic  origin.  I  shall 
refer  to  these  later  in  my  remarks  upon  paracentesis. 

In  certain  instances  of  tuberculous  pericarditis  it  has  been  noted  that 
there  was  no  evidence  of  tuberculous  deposit  in  the  adhesions  which 
were  present.  In  those  instances  more  numerous,  where  tubercles  are 
discovered  in  the  adhesions,  they  may  appear  like  grayish  areas  at  the 
line  of  union  of  the  parietal  with  the  visceral  layer.  In  1048  autopsies 
Wells2  found  tuberculous  pericarditis  10  times,  which  formed  about  8 
per  cent,  of  all  cases  of  pericarditis  recorded  by  him.  It  is  not  limited 
to  adults,  but  may  occur  quite  frequently  in  childhood  or  infancy.  It  is 
more  frequent  among  men  than  women.  Baginsky  reports  15  cases  in 
4500  autopsies,  and  of  these  4  were  purulent.  In  Osier's  autopsies,  1000 
in  all,  there  were  7  instances  of  tuberculous  pericarditis.3 

Welch,  in  his  report  from  Johns  Hopkins  Hospital,  states  he  has  seen 
6  cases.  Although  often  spoken  of  as  frequent,  it  is  not  shown  by  ref- 
erences in  Index  Catalogue,  Transactions  of  the  Pathological  Society  of 
London,  etc.  Up  to  1893  Osier  had  seen  only  17  cases,  and  yet  he 
writes  tuberculous  pericarditis  follows  hard  upon  the  rheumatic  form. 
In  Wells'  cases,  where  the  condition  was  miliary  and  chronic,  there  were 
adhesions  and  no  fluid.  In  acute  miliary  eruption,  and  in  those  where 
there  was  caseous  deposit,4  there  was  also  more  or  less  effusion  in  the 
pericardial  sac. 

1  Medical  Record,  November  23, 1901,  p.  831. 

»  Journal  of  the  American  Medical  Association,  May  25, 1901. 

8  The  American  Journal  of  the  Medical  Sciences,  1893,  p.  20.  *  My  second  case. 


136  TUBERCULOUS    PERICARDITIS. 

In  one  instance,  where  no  tubercles  were  shown  in  a  case  of  acute 
pericarditis,  the  inflammation  was  apparently  due  to  toxins  of  tuber- 
cular origin.  This  opinion  was  supported  by  the  fact  that  tubercles 
were  found  extensively  in  other  viscera.  The  tuberculous  cases,  espe- 
cially those  which  are  acute,  result  fatally.  This  seems  to  be  true,  also, 
of  acute  pericarditis  following  pneumonia  or  Bright's  disease,  but  is  not 
true  of  this  complication  of  acute  articular  rheumatism. 

The  forms  of  tuberculosis  as  they  are  found  in  the  pericardium  are 
either  of  miliary  form  or  cheesy  masses.  When  effusion  exists  it  is 
serous,  bloody,  or  purulent.  It  may  be  moderate  or  considerable  in 
amount.  Whenever  the  condition  has  existed  for  some  weeks,  it  is 
probable  that  the  pericardial  sac  becomes  softened  and  dilated,  and 
offers  a  very  insufficient  support  to  the  heart.  The  clinical  evidence 
of  this  softening  and  dilatation  of  the  pericardial  sac  in  disease  is  shown 
by  its  greater  capacity  to  contain  fluid.  Experimentally,  this  capacity 
is  limited  to  about  700  c.c.  of  liquid  when  forced  into  the  sac.1  In 
disease  we  know  much  greater  quantities  of  fluid  may  be  contained. 
Even  when  these  larger  amounts  are  present,  we  can  only  recover  them 
in  part  by  paracentesis,  owing,  as  will  be  shown  later,  to  the  position  of 
the  heart  in  the  fluid.  Soon  the  heart  would  show  signs  of  dilatation, 
and  this  condition  more  surely  and  rapidly  occurs  if  the  heart  walls  are 
subjected  to  any  increased  strain. 

In  some  instances  of  tuberculous  pericarditis,  as  we  know,  adhesions 
with  the  chest  wall  have  developed.  These  adhesions,  if  more  than 
usually  taxed,  are  apt,  sooner  or  later,  to  be  stretched,  and  in  some 
instances  to  give  way.  Under  these  circumstances  the  heart  shows 
signs  of  insufficiency  very  soon. 

As  Sequira2  points  out,  the  dilatation  of  the  pericardium  is  very 
important  from  the  standpoint  of  ultimate  prognosis,  and  this  we  can 
readily  appreciate  when  we  consider  the  immediate  effects  of  hyper- 
trophous  dilatation  where  passive  congestion  of  the  viscera  is  more 
than  likely  to  occur.  Sequira's  observations  are  based  upon  the  history 
of  130  cases  of  acute  pericarditis  and  observations  of  1000  cases. 

In  occasional  instances  the  pericarditis  seems  to  be  due  to  mere  exten- 
sion from  adjacent  parts  in  which  tuberculous  lesions  clearly  exist. 
Under  these  conditions  the  pericarditis,  curious  to  say,  may  occasionally 
be  simply  inflammatory.  This  point  is  affirmed  by  Osier.  Such  in- 
stances have  also  been  noted  where  the  extension  came  from  a  case  of 
non-tubercular  pleuritis.  Likewise  they  have  been  recognized  as  final 
complications  of  chronic  tubercular  states,  and  as  a  result  of  terminal 
bacteremia  (Wells). 

In  certain  instances  where  the  process  in  the  pericardium  is  an  acute 

i  Chatin.    Kevue  de  Med.,  June  10, 1900.  2  British  Medical  Journal,  June  17, 1900. 


TUBERCULOUS    PERICARDITIS.  137 

one,  tuberculosis  has  not  had  time  to  develop  there,  but  later  we  should 
doubtless  have  discovered  it  if  death  from  other  organs  affected  with 
tuberculosis  had  not  occurred.  Tuberculous  pericarditis  heals  through 
the  formation  of  fibrous  adhesions.  In  some  forms,  especially  the  caseous, 
the  healing  may  be  accompanied  with  calcification.  The  thickening  of 
the  sac  wall  may  become  very  considerable.  This  is  true  of  the  parietal 
wall  particularly.  These  cases  are  often  accompanied  with  a  deposit  of 
numerous  miliary  tubercles.  At  the  same  time  there  is  present  more  or 
less  effusion,  which  may  present  different  characters.  Often  it  is  dis- 
tinctly bloody.  Still  this  is  not  sufficient  to  determine  the  diagnosis,  as 
it  may  take  place  in  other  conditions.  Of  the  11  cases  found  in  liter- 
ature by  Sears,1  6  occurred  in  scurvy,  3  in  rheumatism,  1  in  goitre, 
1  idiopathic,  in  an  alcoholic  subject.2 

Bacilli  may  be  found  in  this  fluid,  although  sometimes  it  requires 
several  careful  examinations  to  reveal  them.3  Osier  reports  1  case, 
quoted  from  Kast,  in  which  tubercles  have  been  found  in  the  pericardial 
effusion.  F.  C.  Shattuck's4  second  case  is  another.  Where  this  exami- 
nation has  remained  negative  the  bacilli  are  revealed  solely  by  means  of 
animal  inoculations.5 

The  proportion  of  successful  inoculations  is  considerable.  It  is  of 
great  value  in  fixing  the  positive  diagnosis  to  be  made.  The  drawback 
to  it  is  the  time  it  takes  to  develop  tubercles.6  It  is  in  the  exudate,  as 
well  as  in  layers  of  pericardium,  that  we  find  tubercle.  When  it 
occurs  in  pericardial  layers  it  oftener  affects  the  parietal  one  and  dis- 
seminates to  the  left  pleura.  Serous  effusion,  when  present,  is  fre- 
quently surrounded  by  fibrous  exudation,  which  in  places  becomes 
adherent. 

The  myocardium  may  be  affected  with  tubercular  infiltration  at  the 
same  time  as  the  pericardium.  The  miliary  form  is  relatively  unim- 
portant as  compared  with  the  caseous.  The  latter  penetrates  deeper  and 
sometimes  perforates  the  cardiac  walls,  and  may  surround  itself  with  a 
fibrinous  clot. 

Formerly  primary  cases  of  tuberculous  pericarditis  were  reported. 
To-day,  thanks  to  a  more  advanced  knowledge  of  pathology,  this 
erroneous  affirmation  is  rarely  met  with.  One  reason  is  because 
lesions  formerly  considered  of  doubtful  nature  are  now  recognized  to 
be  tuberculous.  Hence,  when  such  lesions  are  found  elsewhere  and  by 
their  structure  are  known  to  be  of  old  date,  we  can  readily  appreciate 

1  Boston  Medical  and  Surgical  Journal,  1898,  p.  293. 

2  Churtan.    The  American  Journal  of  the  Medical  Sciences,  1892,  p.  84 ;  also,  Michailoff,  loc, 
<cit.,  1878,  p.  278. 

8  Report  of  my  first  case. 

*  Transactions  of  the  Association  of  American  Physicians,  vol.  xii.  p.  194. 

'  This  was  true  in  my  second  case. 

■•  About  six  weeks  in  guinea-pig. 

10 


138  TUBERCULOUS    PERICARDITIS. 

that  it  is  from  them  that  the  infection  of  the  pericardium  proceeds.  In 
very  many  cases,  without  doubt,  the  infection  is  carried  by  the  blood- 
vessels ;  in  others  the  lymph  channels  are  the  evident  way  of  transport. 

Simple  carrying,  as  it  were,  by  extension  of  a  tuberculous  process 
through  contact,  although  still  admitted,  is  not  so  frequently  allowed 
as  heretofore.  The  ordinary  development  of  tuberculous  pericarditis  is 
to  run  a  subacute  or  chronic  course.  This  course  may  be  such  an 
insidious  one  that  for  a  long  while  the  disease  is  latent,  and  no  obvious 
symptoms  indicate  its  presence.  Indeed,  Osier  reports  only  a  single  case 
in  which,  during  life,  "  the  diagnosis  of  tuberculous  pericarditis  was 
made  with  a  reasonable  degree  of  probability."  If,  however,  there  is 
no  rheumatic  history,  and  tubercles  are  discovered  elsewhere  with  pre- 
vious symptoms  of  pericarditis,  we  should  think  of  the  tuberculous  form. 
The  protracted  course  of  the  disease  and  the  more  marked  irregularities 
of  temperature  may  indicate  its  presence.  Sometimes  the  symptoms 
occur,  but  are  concealed  by  grave  symptoms  of  other  organs  which  are 
affected  from  general  miliary  tuberculosis  as  well  as  the  pericardium. 
It  is  a  fact  also  worthy  of  remark  that,  as  a  result  of  experimental  re- 
searches about  tuberculosis,  while  lungs,  pleura?,  and  mediastinal  glands 
are  usually  attacked,  it  is  a  very  infrequent  circumstance  to  find  the 
pericardium  involved  ;  indeed,  it  is  doubtful  if  there  be  any  well-authen- 
ticated cases  of  it.  The  involvement  of  the  pericardium  through  the 
lymph  channels  and  with  transport  of  tubercle  bacilli  largely  comes 
from  the  lungs,  pleura?,  and  peritoneum.  This  infection  of  cardiac 
lymphatics  is  doubtless  carried  on  indirectly,  so  far  as  the  former 
organs  are  concerned.  Owing  to  the  free  anastomosis  of  the  lymph 
vessels  across  the  diaphragm,  it  is  readily  understood  how  a  tuber- 
culous peritonitis  may  cause  directly  the  development  of  tuberculous 
pericarditis.  Where  the  tuberculous  pericarditis  is  of  caseous  form 
brought  from  mediastinal  glands,  it  is  probable  that  later  on  this 
matter  is  carried  to  and  produces  secondary  infection  of  the  lungs  and 
pleura?. 

In  regard  to  the  question  of  the  frequency  with  which  one  layer  of 
the  pericardium  is  affected  as  compared  with  the  other,  this,  it  appears 
to  me,  is  difficult  of  solution,  despite  the  statement  of  Wells,  and,  in  any 
event,  of  no  practical  moment. 

What  is  affirmed  with  authority  is  that  a  large  proportion  of  cases 
show  tuberculous  deposit  in  mediastinal  lymph  glands  and  pericardium 
at  about  the  same  time,  and  frequently  this  is  true  where  no  tuberculous 
deposit  exists  elsewhere.  We  are  more  likely  to  notice  this  dual  condi- 
tion where  already  the  process  has  become  somewhat  a  chronic  one. 
Effusion  into  the  pericardium  is  more  likely  to  occur,  it  is  stated,  where 
caseous  masses  exist  on  its  surface  than  where  we  find  the  small  gray 
tubercles. 


TUBERCULOUS     PERICARDITIS.  139 

Where  the  myocardium  is  affected  the  disease  comes  primarily,  as  a 
rule,  from  the  pericardium.  The  muscle  of  the  heart  is,  however,  rarely 
thus  diseased.  This  is  especially  true  of  the  ventricle ;  the  auricle  is 
oftener  invaded. 

Tuberculous  pericarditis  may  recover,  it  is  stated.  This  is  rare. 
In  general,  we  may  say  it  is  not  directly  fatal,  and  death  subse- 
quently occurs  from  tuberculous  deposit  in  some  other  important  organ. 
At  this  time  that  of  the  pericardium  may  have  become  quiescent. 
This,  of  course,  occurs  only  in  the  relatively  chronic  forms.  If  it  does, 
we  may  find  fibrous  nodules  in  the  exudate  or  pericardial  walls  as  the 
only  direct  evidence  of  a  tuberculous  lesion.  It  may  be  inferred,  how- 
ever, by  considering  the  evident  tuberculous  condition  of  the  mediastinal 
glands,  and  through  the  fact  that  this  is  the  sole  efficient  cause  of  tuber- 
culous pericarditis  which  can  be  brought  to  light. 

The  most  important  effects,  clinically,  are  those  which  are  seen  upon 
the  heart.  In  some  instances  there  is  no  valvular  lesion  or  structural 
defect  of  the  heart  muscle,  and  yet  there  is  dyspnea,  cyanosis,  and  weak- 
ness of  pulse — all  pointing  to  cardiac  distress.  The  effusion,  by  its 
mere  pressure,  seems  to  be  the  explanation  of  these  symptoms,  and  its 
prompt  removal  is  therefore  the  essential  and  urgent  indication,  so  as  to 
re-establish,  as  far  as  may  be  necessary,  functional  power.  If  this  con- 
dition is  allowed  to  remain,  even  though  life  may  not  be  imminently 
imperilled,  the  heart  soon  shows  the  results  of  the  external  pressure 
against  which  it  contends  by  becoming  enlarged  with  hypertrophous 
dilatation,  and  by  growing  weaker  progressively  and  constantly.  Where 
adhesions  exist  with  the  thoracic  walls,  which  is  often  true  in  these  cases 
whenever  they  tend  to  chronicity,  the  duration  of  life  is  notably  short- 
ened. It  is  equally  true,  only  more  so,  where  the  two  layers  of  the 
pericardium  have  also  become  adherent  and  the  effusion  has  become 
resorbed  or  been  removed  by  paracentesis.  In  these  instances  life  may 
be  measured  by  a  few  months.  This  is  eminently  true  in  pericarditis 
affecting  children.  Lee  Dickinson1  reports  "  one  solitary  case  in  which 
adhesion,  certainly  contracted  in  childhood,  proved  ultimately  harmless." 
The  late  Dr.  Sturges  showed  in  these  cases  that  acute  carditis  is  present, 
usually  of  rheumatic  origin.  Peck2  has  ably  described  in  several  such 
cases  a  condition  of  "  pericarditic  pseudocirrhosis  "  resembling  precisely 
the  mixed  form  of  cirrhosis3  of  the  liver,  which  is  due  to  latent  pericar- 
ditis. The  differential  diagnosis  is  based  upon  :  (1)  Absence  of  etiologic 
factor  of  cirrhosis ;  (2)  a  history  of  pericarditis  supported  with  the  evi- 
dences of  it  from  physical  signs. 

i  The  American  Journal  of  the  Medical  Sciences,  1895,  p.  692. 
2  Ibid.,  1896,  p.  221. 

8  A  case  of  pseudo-atrophic  cirrhosis  of  the  liver,  secondary  to  adherent  pericardium,  is 
reported  by  Dr.  R.  H.  Babcock,  of  Chicago,  in  the  Medical  News,  December  14,  1901,  p.  924. 


140  TUBERCULOUS    PERICARDITIS. 

We  should  not  ignore  the  difficulty  of  explaining  why  pericardial 
adhesions  are  occasionally  followed  by  such  changes.  Wells  gives  sev- 
eral good  aud  sufficient  reasons  why  tuberculous  synechia  is  less  to  be 
feared  than  that  which  occurs  in  purely  rheumatic  cases.  Among  these 
may  be  regarded  slowness  of  growth,  no  valvular  defects,  no  toxemia 
affecting  heart  muscle.  Moreover,  he  states  heart  dilatation  occurs  in 
rheumatism  at  period  of  inflammation  or  later,  when  effusion  is  being 
absorbed. 

In  the  latter  instance,  as  I  have  already  pointed  out,  the  pericardium 
becomes  dilated  and  softened,  and  thus  fails  to  give  the  heart  proper 
support.  In  addition  to  this,  however,  if  the  pericardium  is  attached  to 
the  chest  walls  it  simply  cannot  follow  the  heart,  owing  to  mechanical 
conditions.  For  this  reason,  again,  the  heart  yields  more  and  more  to 
internal  pressure,  and  consequently  becomes  more  and  more  dilated, 
weak,  inefficient,  and  ultimately  powerless. 

In  these  cases  we  often  find  beneath  a  very  thick  pericardium  a  con- 
siderable growth  of  connective  tissue,  together  with  a  deposit  of  fat  in 
the  superficial  parts  of  the  heart  muscle.1  In  rare  instances  are  we  able 
to  demonstrate  the  existence  of  gray  tubercles  in  the  myocardium. 
Where  caseous  deposits  are  found  at  the  autopsy  they  are  more  impor- 
tant because  they  have  penetrated  the  heart  wall  deeply,  and  in  the 
event  of  perforation  they  serve  to  explain  the  transport  of  numerous 
bacilli  in  other  organs  and  the  signs  of  general  miliary  tuberculosis, 
which  are  easily  recognized,  even  during  life. 

The  usual  termination  of  tuberculous  pericarditis  is  death.  This 
may  be  brought  on  directly  by  the  recurrence  of  a  large  effusion,  fre- 
quently hemorrhagic,  which  repeated  tapping  has  failed  to  relieve.  Of 
course  at  times  the  adhesions  which  have  formed  to  chest  walls,  lungs, 
and  diaphragm  seem  greatly  to  shorten  the  duration  of  life ;  but  these 
again  may  never  occur,  and  the  heart  may  simply  float  freely  in  the 
fluid  which  surrounds  it  more  or  less  on  all  sides.2  Often,  as  I  have 
said,  the  fatal  ending  is  immediately  attributable  not  to  the  heart  itself, 
but  to  the  general  miliary  tuberculosis  of  different  viscera  with  which 
the  cardiac  condition  is  associated. 

Death  may  occur  from  an  embolism,  but  this  is  extremely  rare.3 
"  Tuberculous  pericarditis  is  generally  unaccompanied  by  any  symptoms 
referable  to  the  heart,  and  is  almost  always  an  autopsy  finding."  *  With 
this  statement  of  Wells,  corroborated  by  Osier,5  judging  by  my  two 
recorded  cases,  I  should  be  inclined  to  differ. 

For  the  cases  which  are  slowly  and  insidiously  developed  there  is  little 
or  no  local  treatment  to  be  advocated.     This  is  true  of  the  cases  which 

1  Second  case  reported  by  me.  2  See  my  first  case— pathologic  report. 

3  Case  8,  reported  by  Wells.  4  Loc.  cit,  p.  1458. 

6  Already  cited. 


TUBERCULOUS    PERICARDITIS.  141 

terminate  in  synechia  and  where  the  symptoms  are  frequently  very 
obscure.  The  systolic  retraction  of  the  nipple  in  these  instances  is  a 
deceptive  sign,  as  more  than  once  I  have  been  able  to  observe.  In  this 
connection  Lee  Dickinson  states  we  may  have  pulling  in  of  lower  ribs 
with  systole,  but  adds  that  cases  with  this  indication  are  seldom  avail- 
able. The  most  characteristic  of  all  indications  "  are  rapid  progress  of 
the  case  to  the  fatal  end  and  the  signal  failure  of  all  known  means  of 
relief  in  heart  disease."1 

Inasmuch  as  there  is  small  effusion  and  no  obvious  inflammation, 
these  two  conditions  may  not  require  active  interference.  In  those 
instances  in  which  the  onset  of  the  disease  is  acute  it  is  indicated  at 
first  to  limit  the  amount  of  inflammation.  Personally,  I  favor  the  local 
use  of  poultices  or  hot  flannel  stupes.  To  the  former  mustard  may  be 
added ;  the  latter  may  be  sprinkled  with  turpentine.  Equal  parts  of 
soap  liniment  and  turpentine  applied  for  several  hours  on  warm  flannel 
are  recommended.  If  cold  be  employed  I  much  prefer  Leiter's  coil  to 
an  ice-bag.  The  latter  is  difficult  to  keep  in  place  and  causes  distress 
from  cold  at  times,  which  we  cannot  regulate  easily.2  A  small  quantity 
of  morphine  hypodermically  may  be  called  for  to  allay  pain.  In  the 
cases  that  I  have  seen  I  have  not  thought  the  cautery  or  blisters  were 
required  in  the  beginning  of  the  attack.  Later,  I  am  confident,  repeated 
small  fly  blisters  may  limit  the  amount  of  the  exudate  formed.  It  is 
also  possible  that  an  effusion  already  formed  may  thus  be  made  to  dis- 
appear, in  part  or  wholly,  and  more  rapidly  than  it  otherwise  would. 
Despite  what  has  been  said,  it  is  far  wiser  in  many  cases  not  to  attempt 
to  influence  the  pericardial  condition  by  any  local  application.  When- 
ever the  effusion  becomes  considerable  or  excessive,  paracentesis  should 
be  thought  of.  If  the  lips  and  fingers  become  cyanosed — if  there  is 
marked  dyspnoea,  and  weak,  frequent,  irregular  pulse — prompt  with- 
drawal of  fluid  is  necessary  to  preserve  life.  If,  before  paracentesis  is 
performed,  the  exploring  needle  shows  the  presence  of  pus,  it  is  more 
judicious,  in  many  instances,  to  incise  the  sac  freely  and  introduce  a 
drainage-tube.  Of  course,  if  the  condition  of  the  patient  is  imminent, 
paracentesis  may  first  be  performed  and  subsequently  the  more  radical 
operation. 

The  position  of  the  heart  with  respect  to  pericardial  effusions  is  fre- 
quently undetermined.  In  purulent  fluids  the  heart  is  supported  by  or 
floats  upon  the  fluid,  and  is  carried  directly  against  the  chest  walls. 
This  has  been  proven  experimentally.  In  fluids  containing  some  blood, 
or  in  pure  serum,  the  heart  is  surrounded  by  fluid,  as  a  rule,  of  which 
the  larger  quantity  is  in  the  lower  and  left  lateral  portion  of  the  peri- 
cardial sac. 

1  The  American  Journal  of  the  Medical  Sciences,  1896,  p.  696. 

2  Of  course  we  can  put  a  towel  or  flannel  compress  underneath. 


142  TUBERCULOUS     PERICARDITIS. 

Whenever  puncture  of  the  heart  is  indicated,  some  hesitancy  arises 
in  performing  the  operation  on  account  of  the  danger  incident  thereto. 
There  is  risk  of  wounding  the  mammary  artery,  of  entering  the  left 
pleural  cavity,  of  puncturing  the  liver,  of  wounding  the  peritoneum,  or, 
indeed,  of  going  through  the  diaphragm.  Perhaps  the  latter  is  of  no 
special  moment,  as  it  is  the  way  by  which  entrance  to  the  pericardium 
is  occasionally  suggested  or  taken  by  the  surgeon  in  a  radical  operation. 

The  classical  site  for  aspiration  of  the  pericardium  may  be  regarded 
as  the  left  fifth  interspace,  near  the  sternal  margin.1  Other  regions, 
however,  have  been  tried  more  or  less  successfully — i.  e.,  beyond  the  left 
nipple  and  near  the  outer  line  of  cardiac  dulness ;  in  the  right  fourth 
intercostal  space ;  in  the  angle  of  the  xiphoid  cartilage  and  the  margin 
of  the  left  costal  arch.  The  right  interspace  is  specially  indicated  by 
Dr.  Rotch,  of  Boston,  in  those  cases  where  he  has  found  dulness  over 
this  area.2  Dr.  F.  C.  Shattuck,  in  his  able  paper  before  the  Association 
of  American  Physicians,  Washington,  1897,  has  tried  different  points 
for  aspiration  of  pericardium,  with  satisfactory  and  sterile  results. 

On  one  occasion  where  a  small  quantity  of  fluid  was  withdrawn,  later 
the  autopsy  showed  at  least  one  pint  of  fluid  in  the  sac.  It  may  be 
inferred  in  such  cases  that  the  fluid  thus  discovered  was  produced 
during  the  agony  or  after  death.  It  seems  to  me  more  probable  that  it 
was  in  the  pericardial  sac  during  life,  but  could  not  be  aspirated  on 
account  of  the  position  of  the  heart  and  the  wrong  point  of  puncture. 
In  this  connection  I  am  glad  to  be  able  to  refer  to  a  recent  able  article 
by  Dr.  O.  Damsch,3  which  settles  definitely,  it  may  be,  most  points 
hitherto  questionable  about  the  position  of  the  heart,  that  of  the  effu- 
sions, and  the  point  where  we  should  always  try  paracentesis.  Dr. 
Damsch  made  injections  experimentally  into  the  pericardium,  the  sub- 
ject being  in  the  upright  position,  for  the  purpose  of  determining  the 
position  assumed  by  the  pericardial  exudate.  Small  amounts,  he  found, 
collect  in  the  lower  and  anterolateral  portions  of  the  pericardium,  caus- 
ing approximation  of  the  right  anterior  portion  of  the  pericardium  to 
the  chest  wall.  The  heart,  when  of  normal  size,  was  always  found 
pressed  against  the  posterior  portion  of  the  pericardium,  the  fluid  occu- 
pying the  anterior  portion.  In  cases  in  which  the  heart  was  hyper- 
trophied  it  was  pressed  upward  and  anteriorly,  Its  increased  size, 
according  to  Damsch,  causes  it  to  fill  the  whole  space  between  the 
anterior  and  posterior  chest  walls,  and  therefore,  since  the  fluid  collects 
in  the  lower  part  (pericardium),  the  heart  must  be  pressed  upward. 

1  Roberts  states  (Trans.  Surg.  Assoc.)  that  this  point  of  election  "  will  not  assure  safety  to 
the  pleura." 

2  The  clinical  conclusion  from  Damsch's  experiments  was  that  "first  sign  of  pericardial 
effusion  would  be  an  area  of  dulness  in  heart-liver  angle,  as  taught  by  Rotch."    (Lot.  cit.) 

3  Gould's  Year-book,  1901,  pp.  178,  179. 


TUBERCULOUS     PERICARDITIS.  143 

"  From  his  experiments  he  decides  that  the  best  position  for  puncture  is 
well  down  toward  the  lower  part  of  the  pericardium."  He  also  decides 
that  puncture  in  the  fifth  or  sixth  intercostal  space  (left)  next  to  the 
sternum,  directing  the  trocar  somewhat  inward,  is  the  safest  method  and 
location  of  paracentesis.  Thus  performed  there  is  no  danger  of  wound- 
ing either  heart  or  pleura.  If  the  heart  is  normal  the  fluid  is  in  front 
of  it  and  at  lower  part  of  pericardium ;  if  the  heart  is  enlarged,  which 
it  usually  is,  it  is  floated  upward  and  out  of  danger. 

Aspiration  of  the  pericardium  relieves,  without  doubt,  for  a  while 
imminent  symptoms,  and,  as  an  operation  of  urgency,  should  be  em- 
ployed unquestionably.  When  we  come  to  consider  it  as  a  curative 
means  it  is  of  less  value.  I  have  seen  the  fluid  recur  several  times 
after  it  has  been  removed,  and  that,  too,  in  a  relatively  short  period. 
This  statement  is  true  of  instances  in  which  the  pericarditis,  either  at 
that  time  or  subsequently,  was  known  to  be  tuberculous.  One  is  thus 
led  to  ask  whether  in  these  instances  it  is  not  preferable  to  perform  a 
radical  operation  with  proper  surgical  technic  and  thorough  drainage 
of  the  pericardium.  In  purulent  cases  the  general  consensus  of  good 
surgical  judgment  is  to  that  effect.  In  tubercular  cases  where  the 
effusion  is  not  purulent  it  may  be  also  a  wiser  procedure  than  simple 
puncture,  because  through  the  open  wound  the  finger  may  be  intro- 
duced and  large  masses  of  fibrin  extracted.  These  masses,  if  allowed  to 
remain  in  situ,  inevitably  delay  cure  by  allowing  fluid  to  re-form  rapidly. 
After  a  reproduction  of  fluid  on  one  or  several  occasions,  adhesive  peri- 
carditis may  and  does  develop,  and,  sooner  or  later,  we  have  to  do  with 
a  seriously  crippled  heart.  There  might  be  a  chance  of  obviating  this 
by  means  of  the  canula  left  in  place,  and  the  use  through  it  of  some 
form  of  alterative  injection.  Rendu1  reports  such  a  case  of  cured 
tuberculous  pericarditis.  The  modifying  injecting  fluid  employed  by 
Rendu  was  a  solution  of  pure  camphorated  naphtol. 

What  is  true  in  cases  where  effusion  has  been  withdrawn  as  regards 
some  of  the  results  to  heart  fibre  is  true  where  we  leave  the  fluid  in  the 
pericardial  sac  and  do  not  attempt  to  remove  it.  By  and  by  underneath 
the  thickened  layer  there  comes  a  large  layer  of  fat.  This  fat  finally 
penetrates  the  heart  wall  between  the  muscular  fibres,  and,  in  connection 
with  a  deposit  also  of  cellular  tissue,  leads  to  fatty  degeneration  of  the 
heart  structure,  and  later,  perhaps,  to  combined  fibroid  changes. 

As  regards  serous  effusions,  even  though  large  in  amount,  such  as  we 
meet  with  as  a  complication,  especially  of  acute  articular  rheumatism 
and  occasionally  in  nephritis,  these  rarely  require,  puncture,  in  my 
judgment.     Whenever  the  indication  arises,  unless  the  condition  be  very 

1  Journal  of  the  American  Medical  Association,  1901,  p.  1432.    Also,  Bull,  de  la  Soc.  de 
H3pitaux  de  Paris,  March  21,  1901. 


144  TUBERCULOUS     PERICARDITIS. 

imminent,  I  am  of  the  opinion  that  one  or  a  succession  of  fly  blisters  over 
or  near  the  heart  will  accomplish  all  that  is  urgently  required.  It  is 
not  essentia],  moreover,  that  much  fluid  be  removed  from  the  pericar- 
dium in  these  cases  so  as  to  promote  absorption ;  a  small  quantity  is 
sufficient.  The  proof  of  this  is  that  often  after  aspiration  of  the  peri- 
cardium, where  very  little  fluid  has  been  actually  removed,  a  notably 
beneficial  effect  quickly  follows.  The  same  thing  results  from  a  severe 
counterirritant  or  revulsive.  How  this  acts  (blister)1  I  am  not  quite 
sure.  Evidently  there  is  no  immediate  vascular  connection  between  the 
skin  in  the  precordial  region  and  the  heart  itself,  and  for  this  reason  it 
would  seem  as  though  the  blister  would  do  as  much  good  were  it  placed 
over  a  region  far  removed.  Certainly,  if  mere  reflex  action  comes  into 
play  it  is  possible.  And  yet,  somehow  or  other,  I  am  a  believer  in  its 
good  effects  applied  over  the  precordium,  and  I  do  know  that  revulsion, 
irritation,  or  heat  locally  over  the  heart  is  of  great  practical  value  in 
adding  to  its  power.  I  can  readily  conclude,  therefore,  that  wherever 
effusion  in  large  amount  is  partly  passive,  increased  heart  action  may 
be  remedial  in  a  very  distinct  and  rapid  manner. 

With  respect  to  the  operation  of  paracentesis  versus  the  use  of  coun- 
terirritation  in  those  cases  where  the  effusion  is  limited  and  probably 
serous,  we  should  always  have  in  view  the  possibility  of  change  to  a 
purulent  effusion  caused  by  the  little  operation  itself,  especially  if  per- 
formed with  the  ordinary  trocar  and  canula.  With  proper  aseptic  pre- 
cautions and  the  use  of  the  aspirator,  this  to-day  may  be  regarded  as  a 
negligible  quantity.  Moreover,  it  is  known  that  but  one  case  has 
resulted  fatally  following  the  puncture.  "  With  this  exception  all  the 
patients  were  greatly  relieved  by  the  removal  even  of  a  small  amount  of 
fluid,  and  many  recovered  completely  who  probably  would  have  died  if 
the  operation  had  not  been  performed."2 

In  purely  purulent  effusions  it  is  now  generally  admitted  that  surgery 
with  open  wound,  with  or  without  drainage,  should  alone  be  considered. 
Porter's  case3  and  others  still  prove  this.  Only  lately,  for  example, 
H.  Lilienthal  has  had  a  successful  radical  operation  in  a  case  of  purulent 
pericarditis.  Here  aspiration  had  proved  insufficient.  In  Lilienthal's 
case  a  portion  of  the  fifth  left  costal  cartilage  was  resected  close  to  the 
sternum  under  local  anesthesia.  Forty  ounces  of  fluid  were  removed 
from  the  pericardial  sac.4 

In  another  case,  reported  by  Ogle  and  Allingham,  the  pericardium 
was  opened,  a  large  quantity  of  pus   removed,  and  the  pericardium 

1  Dr.  Shattuck  never  uses  blisters.    Drs.  Tyson  and  Rotch  would  not  let  them  go. 
s  The  American  Journal  of  the  Medical  Sciences,  1897,  p.  458. 

3  The  only  case  ever  treated  by  incision  in  Massachusetts  General  Hospital  (F.  C.  S.).    Boston 
Medical  and  Surgical  Journal,  May  6, 1897,  p.  438. 

4  New  York  Medical  Record,  November  25,  1900. 


TUBERCULOUS    PERICARDITIS.  145 

cleansed,  without  interference  of  the  action  of  the  heart  and  with 
decided  benefit  to  the  patient.  It  was  shown  in  this  instance  that  the 
heart  can  be  handled  without  harm.  It  is  therefore  advisable  to  treat 
these  cases  precisely  as  we  would  an  empyema.  Indeed,  the  operation 
is  more  indicated  than  that  of  empyema,  because  the  walls  of  the  cavity 
are  better  able  to  contract  and  finally  lead  to  complete  obliteration.  We 
know  the  outcome  in  empyema,  where,  to  reach  the  best  obtainable 
result,  portions  of  several  ribs  must  often  be  resected.  Even  then  we 
have  to  deplore  many  incomplete  successes. 

Finally,  in  the  operation  by  opening  and  drainage  we  have  really  the 
only  legitimate  hope  of  entire  recovery.  No  one  has  insisted  upon  this 
operation  more  strenuously  than  Dr.  J.  B.  Roberts  since  1876.  In  a 
late  paper  he  reiterates  his  findings.  Very  properly  he  says,  "  the 
diagnosis  of  the  purulent  character  of  the  effusion  was  only  determined 
by  exploratory  puncture."1  And  "this  should  be  done  at  the  upper 
part  of  the  left  xiphoid  fossa  close  to  the  top  of  the  angle  between  the 
seventh  cartilage  and  the  xiphoid  cartilage."  2 

"  The  prognosis  is  good,"  says  Dr.  Roberts,  "  in  pericardotomy  for 
pyopericardium.  In  a  table  of  26  collected  cases  10  recovered  and  16 
deaths  were  shown.  This  gave  a  percentage  of  recovery  of  38.4.  Of 
the  fatal  cases  at  least  9  were  septic,  and  all  the  others  who  died  had 
complicated  lesions,  such  as  pleuritis,  or  pulmonary,  cardiac,  or  renal 
lesions."  3 

"  The  results  obtained  by  incision  and  drainage  in  tubercular  peri- 
tonitis suggest  that  drainage  in  tuberculous  pericarditis  may  lead  to  a 
permanent  cure.  The  ease  with  which  the  pericardium  can  be  irrigated 
with  solutions  of  iodoform  would  seemingly  add  to  this  probability  of 
success." i 

After  analyzing  different  cases,  Roberts  writes:  "  These  observations 
and  other  reported  cases  not  here  mentioned  have  almost  convinced  me 
that  incision  is  better  than  aspiration,  even  in  cases  not  supposed  to  be 
purulent.  It  establishes  diagnosis  in  dubious  cases,  avoids  cardiac 
injury,  saves  the  pleura  from  puncture,  affords  complete  evacuation 
of  effusion,  permits  extraction  of  thick  pus  and  membranous  lymph, 
and  gives  opportunity  for  disinfection  of  the  sac  when  that  is  neces- 
sary." 5 

Porter  cites  one  successful  case  of  incision  in  serous  pericarditis  where 
puncture  failed  to  relieve.6 

Personally,  so  far  as  tuberculous  cases  are  concerned,  I  agree  with 
Dr.  Roberts.  Ordinarily,  in  cases  of  simple  serous  effusion  of  other 
provenance  I  do  not  believe  incision  is  called  for,  and  if  any  operative 

1  Boston  Medical  and  Surgical  Journal,  May  27, 1897,  p.  522.  2  Loc.  cit. 

8  Loc.  cit.  *  Transactions  of  the  American  Surgical  Association,  1897,  p.  108. 

6  Loc.  cit.  •  Transactions  of  the  Surgical  Association,  vol.  xv. 


146  TUBERCULOUS     PERICARDITIS. 

interference  is  required  I  still  prefer  paracentesis.  If  irrigation  be 
employed  as  an  adjunct  in  incision  the  outflow  of  fluid  must  be  unim- 
peded, or  death  may  rapidly  result  from  it. 

In  regard  to  the  technic,  it  is  not  necessary  to  say  more  than  to  point 
out  that  the  best  operation  is  the  one  usually  which  permits  best  drainage 
in  a  given  case.  In  one  instance  it  may  indicate  resection  of  the  fourth 
or  fifth  rib  on  the  left  side;  in  another  the  pericardium  should  be  opened 
from  below  and  through  the  insertion  of  the  diaphragm  near  the  central 
tendon. 

It  should  be  remembered,  in  my  judgment,  that  the  question  of  radical 
operation  for  pericarditis  with  effusion  is  different  in  one  very  important 
particular  from  that  of  pleurisy  with  effusion.  There  are  two  lungs ; 
there  is  only  one  heart.  A  patient  may  do  fairly  well  a  long  time  with 
pleuritic  adhesions,  a  retracted  chest  wall,  and  an  atelectatic  and  fibroid 
lung.  No  patient  will  continue  long  to  be  in  any  degree  comfortable  or 
active  who  has  adhesive  pericarditis  as  a  sequela  of  large  and  long-con- 
tinued effusion,  with  the  pathologic  changes  of  heart  walls  which  inva- 
riably follow  sooner  or  later. 

To  those  who  have  had  small  clinical  experience  with  these  cases,  and 
who  may  be  led  to  believe  that  the  liability  of  heart  puncture  is  slight, 
I  would  point  out  that  the  anatomical  relations  of  the  pericardial  sac, 
despite  Dr.  Damsch's  researches  with  the  chest  walls  and  left  pleura,  in 
many  instances  are  very  perplexing  and  variable.  As  to  the  differential 
diagnosis  of  pericardial  effusion  with  a  heart  merely  enlarged,  while  this 
is  often  very  simple  and  requires  no  great  medical  acumen,  there  are 
occasions  when  the  most  careful  use  of  physical  methods  of  exploration 
will  leave  one  in  a  state  of  great  uncertainty.  Again,  I  have  had  to  do 
with  cases  where  I  was  confident  there  was  a  large  effusion  and  no  risk 
in  introducing  a  small  trocar  connected  with  the  aspirator.  Unfortu- 
nately, my  diagnosis  was  incorrect,  manifestly  on  one  occasion,  and 
instead  of  withdrawing  fluid  from  the  pericardium  my  aspirating  needle 
penetrated  the  heart  wall.  This  was  obvious  by  reason  of  the  fixed 
position  and  special  movements  transmitted  to  the  canula  when  the 
trocar  was  withdrawn.  In  this  instance  no  great  or  immediate  harm 
resulted.  Still,  it  is  an  accident  to  be  avoided,  as  far  as  possible,  by 
great  care  and  attention. 

Orphuls  reports  a  case  where,  at  the  autopsy,  the  end  of  a  trocar 
needle  was  found  in  the  scar  tissue  at  the  upper  portion  of  the  interven- 
tricular septum.  This  needle  probably  broke  off  in  an  exploration  or 
in  a  previous  operation  of  paracentesis.1  Loison2  affirms,  also,  that  in 
wounds   of  the   heart   and   pericardium  the  "  prognosis  is  not  always 

1  British  Medical  Journal,  January  27,  1900. 

2  The  American  Journal  of  the  Medical  Sciences,  1900,  p.  218. 


TUBERCULOUS     PERICARDITIS.  147 

grave."  The  judgment  is  strengthened  by  the  statistics  collected  both 
by  Fischer  and  himself.  On  the  other  hand,  Rotch  has  "known  of  a 
case  where  pricking  the  heart  with  an  aspirator  needle  caused  sudden 
death,"  and  Janeway  one  where  the  aspirating  needle  tore  the  heart, 
causing  death. 

Formerly,  so  as  to  avoid  just  such  mishaps,  I  had  constructed  for 
myself  a  modified  Roberts  canula.1  This  is  a  very  good  instrument 
when  kept  in  proper  order.  It  is  a  little  complicated,  however,  and 
requires  to  be  looked  after.  All  that  precedes  acquires  additional  inter- 
est, if  we  recognize,  as  many  do,  that  the  ordinary  medicinal  remedies 
as  applied  to  the  treatment  of  pericarditis  with  effusion  (especially  the 
tuberculous  form)  have  very  little  value. 

I  am  not  aware,  once  pericarditis  has  become  developed,  that  any 
remedy  given  internally  abridges  its  duration  or  changes  its  course  very 
perceptibly.  I  acknowledge,  of  course,  in  a  few  instances,  that  the 
heart  needs  special  stimulation  in  view  of  the  failure  that  may  come  on 
suddenly  or  by  degrees.  The  alkaline  treatment  may  prove  very  useful 
in  giving  strength  to  cardiac  contraction — more,  indeed,  than  the  use  of 
digitalis.  This  would  be  in  accord  with  the  experiments  of  Gaskell.2 
I  also  know  that  in  a  few — a  very  few  sthenic  cases — aconite  may  be 
indicated  for  a  short  time  to  lower  blood  tension  and  decrease  the  rapidity 
of  the  pulse ;  but  that  is  about  all  there  is  to  do  in  the  acute  stage  by 
way  of  the  mouth.  Locally,  as  I  have  already  pointed  out,  the  ice-bag 
or  poultices,  blood-letting  (leeches  and  cups),  are  useful  where  there  is 
pain  or  great  increase  of  heart  action.  Beyond  some  degree  of  soothing 
or  quieting  thus  produced,  we  should  not  count  upon  a  great  return. 
The  prophylactic  measures  to  be  employed  have  to  do  solely,  it  seems  to 
me,  with  the  efficient  causes  of  tuberculous  pericarditis  which  prevail, 
be  it  possibly  pleurisy,  pneumonia,  sepsis  of  some  sort,  or  mere  exposure, 
fatigue,  or  debauch. 

As  we  know  already,  tuberculous  pericarditis  may  show  itself  when 
we  have  had  little  or  no  suspicion  of  its  presence.  It  may  also  be 
ushered  in  with  so  few  obvious  symptoms  or  signs,  local  or  general,  that 
except  in  an  accidental  way  it  is  not  discovered  during  life.  There  are 
many  examples,  indeed,  where  the  presence  of  the  disease  was  ignored 
during  life,  and  only  ultimately  revealed  by  the  findings  at  the  autopsy. 

Appended  is  an  abstract  of  the  history  of  my  second  case  : 

History  of  Case  of  Tuberculous  Pericarditis  (No.  2).  B.  F.,  married, 
a  hod- carrier,  born  in  the  United  States,  aged  thirty-eight  years,  was 
admitted  to  St.  Luke's  Hospital  under  my  care,  March  19,  1901. 
Family  and  personal  history  negative,  save  that  he  was  a  somewhat 


1  The  Medical  Record,  March  29, 1884,  p.  361. 

2  The  American  Journal  of  the  Medical  Sciences,  1896,  p.  696. 


148  TUBERCULOUS     PERICARDITIS. 

excessive  drinker  of  beer  and  whiskey.  Present  illness  began  four 
months  ago,  after  a  debauch,  with  pain  in  his  right  side.  No  cough, 
chills,  or  vomiting.  The  pain  in  the  side  lasted  a  month,  when  he  began 
to  cough,  expectorated  blood-stained  mucus,  had  some  fever,  with  after- 
noon exacerbations,  and  became  weaker.  Two  weeks  ago  pain  in  the 
precordial  region,  with  palpitations,  developed ;  also  at  times  dyspnoea. 
No  swelling  of  the  feet. 

Physical  examination  shows  marked  increase  of  cardiac  dulness,  rapid 
heart  action,  and  a  high-pitched  systolic  murmur,  heard  between  the 
nipple  (left)  line  and  sternum.  Thoracentesis  gave  serous  fluid  in  right 
pleural  cavity.  Temperature,  99.3°  F. ;  pulse,  100 ;  respiration,  49. 
Urine,  acid,  1020,  no  sugar,  no  albumin,  few  leukocytes.  No  tubercle 
in  sputum. 

X-ray  examination  shows  shadow  corresponding  to  line  of  cardiac- 
percussion  dulness. 

Microscopic  examination  of  blood  negative  ;  also  examination  of  eyes 
negative. 

April  25th.  Guinea-pig  inoculated  with  fluid  from  right  pleura.  On 
May  19th  tubercle  found  in  cheesy  pus  from  enlarged  lumbar  glands  of 
guinea-pig. 

May  26th.  Patient  paralyzed  on  right  side.  Soon  became  comatose 
and  died  the  same  day.  During  sojourn  in  the  hospital  the  patient  was 
feverish,  with  pronounced  irregular  rise  in  the  afternoon. 

Autopsy,  made  by  Dr.  N.  E.  Ditman,  resident  pathologist,  showed 
much  thickened  pericardium  ;  sac  contained  eight  ounces  of  yellow,, 
turbid  fluid.  Heart  enlarged,  muscle  pale,  and  covered  by  a  layer  of 
subpericardial  fat ;  valves  normal,  save  a  slight  atheroma  of  one  flap  of 
mitral.  Dungs,  liver,  spleen,  meninges,  and  peritoneum  showed  dissemi- 
nated miliary  tubercles. 

Microscopic  examination  showed  cheesy  degeneration  and  numerous 
giant  cells  throughout  the  pericardium.  In  the  layer  of  fat  over  the 
heart  and  beneath  the  pericardium  were  numerous  small  masses  of  small 
round  cells,  and  in  each  mass  giant  cells  were  present.  The  heart 
muscle,  superficially,  was  infiltrated  with  fat.  More  deeply  there  was 
a  moderate  small  round-cell  infiltration  between  the  muscle  bundles,  and 
in  places  the  latter  are  separated  by  connective  tissue ;  connective  tissue 
of  bloodvessel  walls  increased  in  amount. 


A  STUDY  OF  SOME  C1RRHOSES  OF  THE  LIVER. 


No  doabt  the  majority  of  practitioners  believe  they  know  pretty 
well  about  cirrhosis  of  the  liver.  It  is  a  common  affection,  particularly 
in  hospitals  and  dispensaries.  In  its  advanced  stages  it  is  readily  diag- 
nosed, as  a  rule. 

In  regard  to  its  prognosis  and  treatment :  These  appear  relatively 
simple  in  that  formerly  at  least  it  was  assumed  by  very  many  that  we 
had  to  do  with  a  fatal  complaint ;  and  as  for  remedial  measures,  they 
resolved  themselves  into  few,  among  which  paracentesis  at  the  last 
stage  only  was  imperative,  mainly  to  relieve  distress.  How  far  such 
notions  to-day  are  removed  from  truth  I  shall  endeavor  to  show  later. 

That  the  liver  is  a  difficult  organ  to  study  and  know  accurately 
few  will  deny  whose  opportunities  and  mental  make-up  prove  them 
competent  observers.  As  compared  with  other  abdominal  or  thoracic 
organs,  where  does  it  stand  ?  The  lungs  can  be  inspected,  palpated, 
percussed,  auscultated,  and  in  a  way  measured.  So,  perhaps,  can  the 
liver ;  but  in  the  former  case  we  seem  to  be  in  more  accurate  touch 
latterly  by  reason  of  sputa  examinations  under  the  microscope  and 
inoculation  experiments.  The  heart  and  its  disorders  have  been  the 
source  of  so  many  investigations  in  the  physiological  laboratory,  so 
many  accurate  clinical  observations  in  the  office  and  the  class  room, 
hospitals,  and  dispensaries— everywhere  and  at  all  times — that  little 
new  may  be  added.  With  the  advent  of  physiological  chemistry,  the 
use  of  the  microscope,  and  the  opportunity,  daily  or  hourly  almost,  of 
knowing  precisely  what  the  urine  shows,  the  kidneys  as  organs  are  very 
clear  to  us.  With  the  liver,  on  the  contrary,  much  seems  still  conjec- 
ture and  hypothesis.  We  speak  of  its  torpidity,  engorgement,  anaemia, 
its  functional  derangements,  its  organic  lesions,  with  glibness  at  times  ; 
and  yet  there  is  much  that  is  obscure  about  its  functions,  healthy  and 
morbid,  that  is  by  no  means  evident,  and  about  which  there  are  very 
honest  and  almost  irreconcilable  differences. 

In  this  connection,  only  very  lately,  Dr.  Goodhart  writes  :  "  The 
largest  organ  of  the  body,  its  imports  and  exports  must  be  enormous, 
and  from  the  familiar  way  in  which  it  is  spoken  of  there  cannot  be 
a  man  in  the  whole  world  who  does  not  think  he  knows  all  about  it. 
But  what  are  the  facts  ?  We  know  something  about  the  physiology 
of  the  liver  ;  but  this  knowledge  has  been  mostly  obtained  by  experi- 
mentation on  the  lower  animals,  by  observations  that  occasional  cases 


150  CIRRHOSES    OF    THE    LIVER. 

of  disease  afford  us,  and  by  certain  inferences  that  we  draw — very- 
much  at  second  hand — from  the  changes  produced  by  disease  in  the 
organ.  But  all  these  things — valuable  as  they  are,  and  without  which 
where  we  should  be  I  do  not  know — yet  are  very  far  from  giving  us 
that  real  and  intimate  knowledge  of  the  living  organ  that  we  require 
to  enable  us  to  treat  its  diseases."1 

Should  this  not  be  adequate  reason  why  we  approach  the  study  of 
the  cirrhoses  with  much  diffidence  and  full  recognition  of  our  deficien- 
cies, even  in  the  role  of  an  upright  reporter  ?  "  Good  men  and  true  " 
have  essayed  this  work  faithfully  in  the  past,  and  told  us  many  things 
we  should  know.  A  great  deal  more  is  required,  much  research  remains 
to  be  done,  and  only  by  degrees  may  we  legitimately  hope  to  secure 
truth — entire  and  with  full  details. 

In  what  relates  to  the  cirrhoses  there  are  many  undetermined  ques- 
tions. The  views  ordinarily  held  are  not  entirely  correct.  In  the  first 
place,  the  clinical  facts,  the  more  we  become  conversant  with  them,  do 
not  justify  invariably  the  gloomy  prognosis  of  these  affections  which 
has  been  entertained.  Instead  of  separating  with  discrimination,  there 
has  been  confusion,  because  all  forms  of  the  disease  have  been  thrown 
together  and  included  as  one.  In  fact,  here  as  elsewhere,  the  work  of 
the  dead-house  has  reigned  supreme  for  a  time,  and  the  close  watching 
of  patients  during  life  has  been  deemed  of  lesser  value,  when  it  should 
always,  as  I  believe,  be  the  first  thought  of  every  good  physician.  How, 
indeed,  can  we  treat  a  patient  properly  unless  we  know  just  what 
symptoms  he  presents  during  life  and  in  what  manner  and  to  what 
degree  function  was  disturbed  ?  Everyone  who  has  grown  gray  in 
harness  and  whose  experience  has  widened  and  deepened  knows  that 
the  morgue  and  the  laboratory  by  themselves  ignore  too  much  and  too 
often  the  intricate  and  obscure  of  our  economy  in  a  dynamic  sense, 
and  hence  must  be  always  controlled,  as  it  were,  from  the  horse-sense 
point  of  view  of  even  the  humbler  humdrum  daily  worker  at  the  bed- 
side.2 

There  are  different  forms  and  degrees  of  cirrhosis.  Not  all  at  once 
and  every  time  does  the  final  atrophic  stage,  with  its  irremediable 
anatomical  conditions  and  its  absolutely  gloomy  horoscope,  show  itself. 
This  form  is  slow  and  insidious  of  development.  At  first  it  is  not 
recognized  ;  there  are  few  or  no  symptoms  we  can  attach  to  it.  At 
best  we  can  only  be  suspicious.3  If  we  have  to  do  with  a  chronically 
hard  drinker  of  beer  or  spirits,  of  course,  we  think  of  the  liver  and 

1  British  Medical  Journal,  August  3,  1901,  p.  251. 

2  Vide  Andrew  Clark,  British  Medical  Journal,  February  3, 1883,  p.  191 :  "  Address  on  Clini- 
cal Investigation  before  the  Clinical  Society  of  London." 

3  In  writing  of  early  stages  of  hepatic  cirrhosis,  Billings  claims  there  is  a  relatively  large 
number  of  patients  whose  symptoms  are  those  of  neurasthenia,  myalgia,  mononeuritis,  or 
gastro-intestinal  disturbance.— Medical  News,  July  26, 1902,  p.  167. 


CIRRHOSES    OF    THE    LIVER.  151 

fibroid  changes  ;  and  then  if  there  be  palpitations  of  the  heart,  evidences 
of  dyspepsia,  vascular  stigmata  on  the  face,  corpulency,  and  a  some- 
what enlarged  liver  we  cry  a  halt  to  bad  habits,  and  the  outlook  may 
be  sombre.  On  the  same  lines,  if  we  find  loss  of  strength,  inap- 
petence,  and  a  failure  of  nutrition,  as  shown  by  loss  of  weight,  even 
though  the  liver  be  of  normal  size  apparently,  we  cannot  avoid  some- 
what gloomy  forebodings  unless  we  are  able  soou  to  control  habits  and 
regimen.  But  are  we  sure — may  we  be  reasonably  certain — with  such 
vague  characters  that  we  shall  even  later  be  able  to  fix  an  absolute 
and  correct  diagnosis  ?  The  answer — the  only  one — must  be  negative. 
The  sooner  the  better  for  every  medical  student  to  know  that  disease 
does  not  run  closely  at  any  time  along  so-called  prescribed  lines.  It 
varies,  it  differs  ;  one  day  we  see  certain  forms  of  disease,  another  day 
it  is  just  the  contrary.  All  cases  are  in  a  certain  sense  individual, 
personal.  There  is  nothing  wholly  general  and  all-absorbing  about 
any  one  instance.  Take,  for  example,  the  abdominal  effusion  in  cir- 
rhosis— the  ascites  which  in  the  later  stages  is  so  striking,  so  character- 
istic, so  grave  of  import  in  the  eyes  of  many  that  it  seems  like  to  a 
funeral  knell  in  its  fatality.  Is  it  so  ?  May  it  not  appear  soon,  and 
in  its  earlier  stages  may  it  not  be  treated  wisely  and  advantageously  ? 
And  may  not  a  patient  do  well  for  a  long  while,  thus  treated  ?  And 
why  is  this  ?  May  not  very  many  of  the  liver  cells  still  be  function- 
ally healthy,  quite  capable  of  carrying  on  good  nutrition  ?  Is  not 
fibrous  growth  in  the  liver  usually  slow  ?  Does  it  not  leave  many 
lobules  untouched  for  many  a  day  by  its  contracting  power,  and  other- 
wise in  what  degree  is  it  really  pernicious?  These  and  other  queries 
immediately  arise  to  one's  mind.  It  is,  moreover,  a  fact  of  daily  ex- 
perience almost  to  have  patients  come  to  our  office  or  to  out-door  clinics 
in  whom  ascites  is  undetermined.  We  are  unable  to  affirm  positively 
that  it  exists.  And  this  is  true  not  for  one  examination  only,  but  for 
many.  Days,  months,  and  even  years  elapse  with  some  patients  before 
we  can  say  convincedly  this  is  or  this  is  not  a  case  of  hepatic  cirrhosis. 
The  three  principal  forms  of  cirrhosis  which  are  recognized  by 
writers  are  (1)  atrophic,  (2)  hypertrophic,  (3)  syphilitic.  Besides  these 
there  are  so-called  minor,  even  undetermined,  forms.  Usually  the 
latter  are  due  to  passive  congestion,  brought  on  by  pressure  from 
neighboring  tumors  or  indicative  of  some  chronic  disturbance  of  heart 
power,  structure,  or  action.  In  these  instances,  especially  where  the 
heart  is  the  primary  cause,  the  abdominal  ascites  is  merely  a  symptom 
which  is  part  of  a  general  anasarca.  It  may  be,  however,  that  the 
ascites  has  something  special  in  it ;  it  may  stand  by  itself,  as  it  were, 
so  far  as  effusion  is  concerned  in  the  serous  cavities.  Then  we  have 
to  do  with  an  expression  of  cardiac  inefficiency  accompanied  by  one  of 
the  known  effects  of  portal  obstruction  due  to  fibrosis  around  the  vessels 


152  CIRRHOSES    OF    THE    LIVER. 

of  the  liver.  In  these  cases  we  should  look  rather  for  hypertrophy  than 
atrophy.  The  liver  is  enlarged  and  engorged.  It  is  filled  with  blood 
from  overcongestion.  There  may  or  may  not  be  already  marked  fatty 
change,  and  thus,  instead  of  the  dense,  hard,  tough  liver  with  sharp 
lower  margin,  which  is  said  to  characterize  the  cirrhotic  liver,  we  may 
have  a  greasy,  rather  soft  structure,  which  leaves  the  impress  of  the 
finger  upon  its  surface  when  we  press  with  even  very  moderate  force. 
While,  then,  it  may  be  admitted,  and  is  certainly  true  with  limitations, 
that  all  three  forms  of  cirrhosis  of  the  liver  are  characterized  by  in- 
crease of  fibrous  tissue,  which  penetrates  its  structure  and  distributes 
in  somewhat  different  ways  along  the  branches  of  the  interstitial  tree, 
it  is  also  true  that  these  forms  are  all  different  in  many  particulars. 

Their  pathology,  to  begin  with,  is  not  the  same.  In  one  form — the 
hypertrophic — the  fibrous  tissue  is  finer,  less  formed,  accompanied  by 
a  cellular  growth,  and  runs  along  the  smaller  branches  interstitially. 
In  the  atrophic  form  this  fibrous  tissue  is  coarser,  better  formed,  shows 
greater  tendency  to  contract  upon  and  disorganize  liver  cells,  extends 
along  larger  branches  of  the  interstitial  tree,  and  is  not  accompanied 
-by  cellular  growth  to  the  same  degree  at  all. 

In  connection  with  the  increase  of  connective  tissue  it  has  been 
proven  experimentally  that  the  action  of  alcohol  on  the  liver  of 
animals  is  also  to  cause  granular  and  fatty  degeneration  of  the  liver 
cells.  According  to  Vaughan,  the  increase  of  the  connective  tissue 
is  small  in  amount,  and  only  reported  by  some  observers.  Vaughan 
concludes  that  "  the  connective  tissue  changes  are  subsequent  to  and 
dependent  upon  alteration  in  the  hepatic  cells."1  Later  on  he  writes 
that  with  the  clinical  and  experimental  evidence  hitherto  obtained  we 
are  justified  in  believing  "  that  in  alcoholic  cirrhosis  the  pathological 
changes  begin  in  the  hepatic  cells." 

From  what  has  been  said  concerning  the  pathology  and  etiology  of 
atrophic  and  hypertrophic  cirrhosis  it  has  been  shown  that  the  two 
forms  may  exist  as  types.  They  may  also  be  present  combined,  as  it 
were,  in  the  same  individual  and  exist  as  one  disease.  The  atrophic 
form  is  clearly  due,  as  a  rule,  to  alcohol ;  the  hypertrophic  to  infection 
(Vaughan)  ;  but  the  infection  may  precede  or  follow  the  toxic  poison- 
ing, and  the  result  is  a  mixed  form  of  cirrhosis.  These  forms,  both 
clinically  and  at  the  autopsy,  are  very  difficult  of  precise  diagnosis,  so 
intimately  and  curiously  combined  are  their  symptoms  or  lesions.2 

1  Journal  of  American  Medical  Association,  October  5, 1901,  pp.  878,  879. 

2  In  a  patient  I  saw  last  summer,  who  subsequently  died,  the  liver  was  stated  during  life  to 
be  much  enlarged  by  several  very  competent  observers— both  surgeons  and  physicians.  I  was 
able  to  satisfy  myself  after  death,  by  intra-abdominal  digital  exploration,  that  the  liver  was 
not  notably  enlarged.  I  was  also  convinced  that  an  intra-abdominal  mass,  in  close  juxtaposi- 
tion with  the  lower  margin  of  the  liver,  gave  rise  to  an  error  of  diagnosis  in  this  regard, 
although  the  case  was  proven  not  to  be  one  of  cirrhosis  of  the  liver. 


CIERHOSES    OF    THE    LIVER.  153 

la  the  syphilitic  cirrhosis  we  have  those  broad  bands  of  fibrous  tissue 
which  penetrate  between  the  lobules  and  draw  the  liver  down  near  the 
surface  in  such  manner  as  to  leave  the  puckered,  scarred  appearance, 
with  bossy,  prominent,  irregular  masses  between  which  are  so  charac- 
teristic. 

As  to  the  course  and  clinical  symptoms  :  These,  we  shall  see,  differ 
widely  and  obviously  in  many  ways.  In  atrophic  cirrhosis,  for  exam- 
ple, the  main  distinguishing  clinical  feature,  as  we  could  almost 
premise  from  its  pathology,  is  the  evidence  of  marked  portal  obstruc- 
tion— at  least  this  is  true  almost  as  soon  as  the  disease  is  clearly  deter- 
mined. Hence  arises  the  abdominal  effusion,  and  with  this  most 
significant  and  almost  portentous  sign  we  have  hemorrhages  from  the 
stomach  and  bowels.  Sometimes  these  are  small  and  infrequent,  and 
give  no  great  and  immediate  alarm  if  their  quantity  alone  is  consid- 
ered ;  but  considered  from  the  point  of  view  of  their  evident  causation, 
great  apprehension  is  invariably  excited,  and  justly  so.  Shortly  we 
may  have,  and  do  often,  those  abundant  and  depressing  blood  losses 
so  difficult  to  arrest,  and  which  point  to  the  urgent  necessity,  and  none 
too  soon,  of  employing  all  rationally  known  measures  to  ease  up  an 
obviously  crippled  organ  and  to  restore  falling  strength.  How  unfor- 
tunate it  is  in  such  cases  if  the  somewhat  too  enthusiastic  surgeon  finds 
indications  for  abdominal  exploration  or  an  operation  for  internal 
hemorrhoids  !  Jaundice  is  a  rare  sign  in  these  cases1 — at  least  real 
jaundice,  with  urine  loaded  with  bile  pigment  and  acholic  stools.  Of 
course,  the  dull,  earthy  hue  of  the  skin  and  the  subicteric  tint  of 
the  sclerotics  are  frequent  phenomena  which  serve  in  a  measure  to  fix 
our  diagnosis.  Sometimes  "  adhesive  pyelophlebitis  closely  resembles 
the  atrophic  form  of  interstitial  hepatitis.  The  rapidity  with  which 
the  peritoneal  effusion  reforms  after  tapping  is  an  important  diagnostic 
sign."2 

These  cases  of  atrophic  cirrhosis  in  reality  are  long  as  to  duration. 
They  appear  short  merely  because  they  are  unrecognized  prior  to  the 
advent  of  the  ascites,  and  then  the  inevitably  fatal  termination  seems 
to  stand  out  imminently,  since  a  few  months  or  a  briefer  period  may 
bring  about  a  fatal  ending  of  the  case. 

The  first  and  imperative  thing  to  do  'with  these  patients  is  to  lay 
down  the  law  which  forbids  alcoholic  stimulation  in  any  form,  because, 
as  we  know,  in  the  chronic  irritation  thus  produced  we  find  the  imme- 
diate and  efficient  cause  of  the  majority  of  such  cases.  Of  course, 
there  are  degrees  of  injurious  action.     The  man  who  has  drunk  heavy 

1  Where  fatty  degeneration  and  cirrhosis  coexist  profound,  persistent  jaundice  is  less  infre- 
quent. A  patient  thus  affected,  as  shown  by  the  autopsy,  died  in  one  of  my  wards  at  St.  Luke's 
Hospital  May  8,  1902. 

3  James  H.  Wilson,  Medical  Record,  December  7, 1901,  p.  909. 

11 


154  CIRRHOSES    OF    THE    LIVER. 

beers  for  a  long  while  and  in  large  quantities,  combined,  it  may  be 
at  times,  with  daily  potations  of  spirits  undiluted  and  containing  fusel 
oil,  is  the  worst  type  with  which  we  have  to  do.  Such  an  one  is  the 
longshoreman,  hodcarrier,  and  other  laboring  man,  or  the  chronic 
loafer  who  comes  to  our  out-door  clinics  or  to  our  hospital  ward,  when, 
on  investigation,  we  find  the  contracted,  small  hobnailed  liver,  which 
shows  the  condition  of  multilobular  cirrhosis  and  also  many  accom- 
panying pathological  changes.  The  spleen  and  pancreas  are  often 
hard  and  functionally  decrepit,  the  kidneys  show  marked  interstitial 
changes,  the  stomach  is  thickened,  atrophied,  and  congested  ;  but, 
above  all,  the  heart  is  weak,  flabby,  degenerated.  Fibrous  myocarditis 
is  sometimes  made  out  at  the  autopsy  ;  more  frequently  we  have  more  or 
less  fatty  change,  apparent  to  the  eye  and  corroborated  with  the  micro- 
scope. The  general  vascular  system  does  not  escape,  and  capillary 
arteriofibrosis  has  run  its  course,  so  that  there  is  scarcely  a  sound 
arterial  coat  to  be  found,  no  matter  what  organ  we  turn  to.  This  is,  in- 
deed, a  gloomy  and,  alas  !  too  true  a  picture.  Alongside,  fortunately, 
we  have  another  far  more  hopeful.  The  man-about-town,  the  broker,  the 
business  man — even  the  lawyer  and  the  not  too  wise  physician — whose 
drinking  consists  in  two  or  three  or  more  "  Manhattan  "  or  "  Mar- 
tigny  "  cocktails  every  day,  taken  upon  an  empty  stomach  and  as  "  a 
pick-me-up,"  as  the  saying  goes  ;  the  genial,  pleasant  fellow  who  gives 
himself  a  rest  of  an  evening,  and  who  frequents  the  club  and  the 
billiard-room,  and  who  before  the  evening  is  gone  has  consumed  several 
drinks  of  "rye"  or  "Scotch"  or  "unsweetened,"  is  also  an  apt 
candidate  for  admission  among  the  cirrhoses  of  the  atrophic  order. 
Fortunately,  such  an  one  drinks  "good  spirits,  as  a  rule,  in  the  sense 
that  it  is  relatively  pure  and  unadulterated.  Moreover,  his  food  is  well 
cooked  and  assimilable.  He  bathes,  and  is  therefore  cleanly  and  has  an 
active  skin  ;  and  with  a  healthier  body,  perhaps,  to  start  with  he  does  not 
suffer  so  soon  or  so  hopelessly  as  the  poor  chap  I  have  previously  con- 
sidered. Moreover,  when  the  first  premonitory  signs  of  disease  occur, 
if  he  be  even  moderately  wise,  he  consults  his  family  physician,  when 
I  would  fain  believe  he  secures  a  mental  and  moral  shaking  up,  with 
which  a  little  useful  medicine  added  thereto  allows  him  to  guard  more 
carefully  his  still  useful  liver  cells,  and  gives  declared  fibrosis  an 
opportunity  to  cease  development  and  extension  for  a  time. 

Without  going  further  in  this  description  I  trust  I  have  been  able 
to  show  and  bring  home  to  my  readers  what  they  all  know,  what  they 
all  feel  and  see  around  them  every  day.  Turn,  now,  to  our  hyper- 
trophic form  of  cirrhosis,  and  what  may  we  note  ?  Here,  instead  of 
atrophy  and  contracture  and  loss  of  size,  we  have  enlargement  and 
increase  of  weight.  In  addition,  there  is  to  be  found  a  singular  devel- 
opment of    new  biliary  canaliculi  on  the  periphery  of    the    lobules, 


CIRRHOSES    OF    THE    LIVER.  155 

which  is  so  distinctly  shown  in  sections  for  microscopic  insight.  This 
latter  division  is  the  one  so  ably  described  by  Hanot,  Charcot,  and 
other  French  writers,  and  about  which  there  is  such  wide  divergence  of 
opinion  elsewhere.  Suffice  it  to  add  that  in  typical  forms  these  must 
be  very  rare,  infrequent  cases.  For  my  own  part,  I  do  not  recall  to 
have  seen  and  observed  a  typical  one — at  all  events,  not  one  where 
the  post-mortem  researches  justified  altogether  a  previous  clinical  diag 
nosis.  In  the  hypertrophic  cirrhosis  of  the  sort  we  do  see  from  time 
to  time  the  fibrosis  as  it  extends  into  the  liver  seems  to  mark  for  its 
own  a  few  cells  here  and  there  throughout  the  structure,  or  certain 
individual  lobules.  In  this  hypertrophic  form  ascites  does  not  often 
occur,  nor  should  we  expect  it  if  we  pay  due  regard  to  the  special  char- 
acters of  the  fibrosis  formation.  Jaundice,  on  the  contrary,  is  a  marked 
and  almost  omnipresent  symptom  ;  and  it  is  the  real  jaundice — not  the 
aborted  state,  so  to  speak — to  which  I  have  referred  in  the  atrophic 
form  of  cirrhosis,  i.  e.,  icteroid  hue. 

Like  to  atrophic  cirrhosis,  haemateniesis  is  not  infrequent,  and,  when 
it  occurs,  abundant  and  very  threatening.  Many  of  these  hemorrhages 
in  cirrhosis  originate  at  the  lower  end  of  the  oesophagus.  They  are 
often  confounded  with  hemorrhages  which  come  from  ulcer  of  the 
stomach.1  In  either  case,  but  especially  the  former,  Ave  should  be 
very  chary  about  the  introduction  of  a  stomach-tube,  as  a  dangerous 
or  even  fatal  loss  of  blood  might  take  place  immediately.  With  the 
hemorrhage  from  the  oesophagus  or  stomach  we  see  developed  many 
acute  symptoms.  There  is  fever,  and  often  the  temperature  ranges 
high.  There  is  delirium  of  an  active  kind,  pointing  to  a  toxaemia  and 
blood  infection.  "Chills  and  sweating  are  not  common"  in  the 
hypertrophic  form  of  interstitial  hepatitis,  ' '  thus  serving  to  differen- 
tiate it  from  impacted  gallstones."     (Wilson.) 

Later  the  patient  may  relapse  into  coma  from  which  there  is  no 
awakening.  Before  these  symptoms  of  delirium  and  coma  become 
manifest  we  usually  have  several  repeated  intermittent  attacks  of  pain, 
with  fever.  The  pain  is  localized  over  the  hypochondrium,  and  the 
liver  is  tender. 

In  these  particulars  we  have  an  approach  to  the  syphilitic  form,  and 
except  for  the  history,  the  different  physical  signs,  and  other  symptoms, 
we  might  have  a  difficult  diagnosis  ;  but  this  is  not  true  for  the  careful 

1  According  to  Knapp  (Medical  Record,  March  1, 1902,  p.  334)  these  hemorrhages  are  some- 
times erroneously  "diagnosed  as  pulmonary  tuberculosis,"  when  they  should  be  considered 
"  cases  of  ulcer  of  the  oesophagus." 

According  to  Bouchard  (Revue  de  M6decine,  October,  1902)  hemorrhages  in  cirrhosis, 
which  occur  outside  the  territory  of  the  portal  vein,  are  in  relation  with  pre-existing  arterial 
lesions,  affecting  various  organs,  and  do  not  depend  upon  abdominal  plethora.  The  arterial 
lesions  are  chronic  degenerative  changes  probably  due  to  arterio-sclerosis. — Boston  Medical 
and  Surgical  Journal,  September  11,  1902. 


156  CIRRHOSES    OF    THE    LIVEE. 

diagnostician,  who  also  considers  the  ordinarily  chronic  course  of  the 
disease. 

As  to  causation,  it  is  obscure.  Frequently  the  spleen  also  being 
enlarged  a  malarial  origin  is  suspected.  There  are  too  few  observa- 
tions accurately  made  in  which  the  plasmodium  has  been  discovered 
to  altogether  justify  this  opinion.  I  rather  believe  that  alcohol 
is  here  again  a  more  probable  and  efficient  factor  in  bringing  on  this 
change  in  liver  structure.  One  statement  would  seem  to  be  borne  out 
by  facts  that  we  do  know,  and  it  is  that  the  obstruction  of  the  bile 
ducts  by  fibrous  tissue  seems  to  account  for  the  genesis  of  the  acute 
symptoms  which  mark  the  course  of  the  disease  and  point  to  inflam- 
matory conditions,  more  or  less  lasting.  According  to  some  authors, 
such  inflammatory  conditions  are  wholly  ignored,  and  they  affirm  that 
an  infective  process  is  the  sole,  undeniable  cause  of  hypertrophic  cir- 
rhosis. In  this  conection  Vaughan1  writes  :  "  With  our  present  knowl- 
edge it  must  be  attributed  in  all  cases  to  infection."  If  this  be  ad- 
mitted, pathologically,  it  may  be  stated  that  "  the  epithelium  of  the 
gall  ducts  is  the  site  of  the  primary  involvement."     (Vaughan.) 

In  the  syphilitic  liver  we  find  marked  induration,  at  times  fairly 
recognizable  by  our  tactile  sensations.  The  liver  itself  is,  as  a  rule, 
larger  than  uormal.  This  is  not  an  invariable  rule,  and  just  the  con- 
trary may  be  found,  no  doubt,  in  those  instances  where  the  fibrous 
contracting  bands  are  broad  and  numerous.  The  gummata  on  the 
surface  of  the  liver  when  they  exist  are  often  easily  recognizable.  Of 
course,  we  may  confound  them  with  malignant  nodules  on  the  one  hand 
or  perhaps  the  hobnailed  condition  of  atrophic  cirrhosis  on  the  other; 
but  the  bossy,  lobular  forms  of  the  tumors,  together  with  the  previous 
history  and  other  signs  of  syphilis,  or,  in  the  absence  of  both,  the 
notable  cachexia  of  cancer,  if  present,  enable  us  to  be  pretty  confi- 
dent as  to  our  differential  diagnosis.  In  reasonable  doubt  an  accurate 
blood  count  with  differentiation  of  white  cells  will  help  us  much.  A 
decided  and  relative  increase  of  lymphocytes  and  of  eosinophile  cells, 
according  to  Neusser  or  Cabot,  would  make  this  point  very  valuable. 
Of  course,  "  a  disappearance  of  the  tumor  after  a  tentative  antisyph- 
ilitic  treatment  argues  most  positively  in  favor  of  gumma."2 

So  far  as  clinical  symptoms  go,  syphilitic  cirrhosis  resembles  one  of 
the  other  forms.  There  may  be  jaundice  and  no  ascites ;  there  may 
be  both  ascites  and  jaundice.3  On  the  other  hand,  there  are  instances 
in  which  neither  sign  is  present.  At  an  advanced  stage,  however, 
ascites  can  usually  be  determined  ;  and  what  is  of  particular  value  is 

1  Ibid.  cit.  2  Einhorn,  Medical  Record,  August  17,  1901. 

*  Stockton  states  when  jaundice  occurs,  even  with  apparent  alcoholic  cirrhosis,  especially 
if  accompanied  by  cachexia,  it  is  well  to  suspect  syphilis. — Medical  News,  June  28,  1902, 
p.  1244. 


CIRRHOSES    OF    THE    LIVER.  157 

the  localized  pain  in  the  right  hypochondrium  which  is  usually  present. 
These  pains  are  not  constant,  as  a  rule,  but  come  on  intermittently,  or 
at  all  events  are  greatly  intensified  if  previously  they  have  been  present 
in  a  mild,  dull  form.  The  pains  during  the  exacerbations  may  become 
so  intense  as  almost  to  resemble  those  of  gallstones.  If  the  disease 
has  existed  for  a  long  while  there  is  decided  loss  of  weight,  but  scarcely 
ever  to  the  degree  which  characterizes  malignant  disease.  Constipa- 
tion and  various  functional  disturbances  of  the  stomach  and  intestines 
are  frequently  present. 

The  congenital  form  of  syphilis  of  the  liver  I  do  not  remember  to 
have  met  with  ;  if  I  have  my  memory  is  too  uncertain  to  be  a  faithful 
reporter.1  By  those  who  have  seen  or  described  it  it  is  said  to  be  a 
diffuse  fibrosis,  where  the  abnormal  tissue  formation  penetrates  into  the 
lobules  or  between  the  cells.  The  fibrous  tissue  is  an  immature  devel- 
opment. The  liver  itself  is  large  and  it  is  accompanied  by  jaundice, 
ascites,  and  emaciation.2  While  as  regards  the  pure  pathology  of 
cirrhosis,  as  Cheadle  says,  there  is  more  or  less  unanimity  among 
writers,  this  is  not  true  of  the  causation  of  symptoms  as  connected  with 
morbid  anatomy,  nor  of  the  course  and  clinical  manifestations  of  the 
disease  in  its  various  forms.  One  of  the  questions  for  settlement  is  to 
know  whether  the  atrophic  form  is  anything  more  than  a  later  stage  of 
the  hypertrophic.  Further,  more  definite  judgment  as  to  Hanot's 
biliary  cirrhosis  is  desired,  and  as  to  whether  hypertrophic  cirrhosis  is 
a  real  entity.  These  and  many  others  are  of  singular  interest.  It  is 
ordinarily  accepted  that  atrophic  cirrhosis  is  mainly  caused  by  alcohol ; 
indeed,  that  it  is  the  essential  cause  in  the  vast  number  of  cases.  Still, 
malaria  has  seemed  to  be  a  sinning  factor  at  times.  Unfortunately,  a 
typical  case  of  malarial  origin  is  rarely  found,  at  least  with  us  in  New 
York.  This  may  be  accounted  for,  and  doubtless  is,  by  the  relatively 
mild  form  of  malaria  from  which  we  suffer.  The  sestivo-autumnal 
sort,  with  the  characteristic  crescents  in  the  blood,  does  not  occur 
often.  They  are  relatively  exceptional.  Now,  it  is  in  just  these  cases  or 
those  of  long-continued  malarial  cachexia,  where  we  find  great  enlarge- 
ment with  fibroid  induration  of  the  spleen  and  also  of  other  abdominal 
organs,  notably  the  kidneys.     Why,  then,  should  we  anticipate  finding 

1  According  to  Osier  it  "  is  rare  and  nearly  always  overlooked." 

2  Vide  Cheadle.  Lumleian  Lectures  for  1900.  It  affords  me  great  pleasure  in  this  connec- 
tion to  speak  with  admiration  of  these  lectures,  and  to  state  that  I  have  freely  used  them  in 
writing  this  paper.  Indeed,  I  have  followed  his  outlines  (Cheadle's)  because  I  could  find 
none  better. 

Since  the  above  was  written,  Dr.  George  G.  Sears  and  Dr.  F.  T.  Lord  have  published  in  the 
Boston  Medical  and  Surgical  Journal  of  September  11, 1902,  a  very  important  paper  on  cir- 
rhosis of  the  liver,  based  on  all  the  fatal  cases  in  the  Boston  City  Hospital  and  the  Massa- 
chusetts Hospital  since  1896  in  which  the  diagnosis  was  proved  by  histological  examination. 
Many  of  their  conclusions,  according  to  the  London  Lancet  of  October  15,  1902,  are  only  con- 
firmatory of  those  published  in  England  by  Dr.  Cheadle  and  by  Dr.  Hale  White. 


158  CTRRHOSES    OF    THE    LIVER. 

well-marked  morbid  effects  of  this  sort  in  the  liver  if,  as  I  do  believe, 
the  liver  as  an  organ  is  not  nearly  so  apt  to  be  much  affected  by 
malarial  poison  as  is  the  spleen  ?  Also,  I  would  state  that  it  is  most 
unusual  for  us  to  discover  cases  of  profound  malarial  poisoning  where 
we  could  absolutely  eliminate  the  disastrous  influence  of  alcohol  from 
the  equation  ;  and  yet  it  is  stated,  even  by  those  who  claim  never  to 
have  seen  a  case  of  malarial  cirrhosis,  that  there  is  nothing  absolutely 
improbable  in  the  assumption,  inasmuch  as  malarial  indurated  spleen 
is  fully  determined.  To  my  mind,  this  reasoning  by  analogy  is  very 
lame  and  inapplicable  to  the  liver,  in  view  of  the  fact  of.  its  very  dif- 
ferent structure  and  functions.  When  we  consider  how  prone  the  liver 
is  to  become  engorged  and  somewhat  cirrhotic  in  all  cardiac  affections 
as  well  as  in  all  obstructive  lung  diseases,  it  would  seemingly  be  doubly 
reasonable  to  eliminate  the  malarial  factor  in  causation,  unless  pretty 
clearly  evident.  I  direct  particular  attention  to  this  statement,  because 
I  know  that  in  most  text-books  malaria  is  insisted  upon  as  a  cause  of 
atrophic  cirrhosis  of  the  liver.  Osier,1  in  this  connection,  writes  :  "  In 
our  large  experience  with  malaria  during  the  past  nine  years  not  a 
single  case  of  advanced  cirrhosis  due  to  this  cause  has  been  seen  in 
the  wards  or  autopsy-room  of  the  Johns  Hopkins  Hospital."  Now,  it 
is  well  known  that  the  malarial  manifestations  found  in  the  city  of 
Baltimore — a  few  indigenous,  many  coming  from  regions  farther  South 
— are  more  virulent  than  those  we  meet  with  in  New  York  or  other 
cities  of  the  North  in  the  United  States. 

Osier  also  writes,2  in  speaking  of  the  liver  :  "  Only  those  cases  in 
which  the  history  of  chronic  malaria  is  definite,  and  in  which  the 
melanosis  of  both  liver  and  spleen  coexist,  should  be  regarded  as  of 
paludal  origin." 

There  seems  to  be  little  doubt,  also,  that  hypertrophic  and  atrophic 
alcoholic  cirrhosis  are  distinct  forms  of  disease  and  not  different  stages 
of  the  same  form.  This  affirmation  seems  reasonable  when  we  consider 
the  very  marked  difference  in  the  distribution  of  the  fibrosis  as  well  as 
of  its  nature  in  the  two  cases.  In  the  one  the  affection  is  markedly 
multilobular ;  in  the  other  it  is  monolobular  in  quite  as  pronounced 
degree.  According  to  Cheadle,  the  error  in  confounding  the  two  dis- 
eases arose  originally  from  the  hypothesis  that  Hanot's  so-called  biliary 
cirrhosis  was  simply  the  hypertrophic  form.  In  many  instances  of  cir- 
rhosis of  the  latter  form  there  is  unquestionably  a  period  when  the  liver  is 
simply  congested  and  enlarged,  and  yet  no  formation  of  abnormal  fibrous 
tissue  is  yet  begun,  not  to  speak  of  any  degree  of  contracture  which 
later  on  may  prevail.  In  these  cases  the  liver  is  said  to  be  much  softer 
than  it  is  where  hypertrophic  cirrhosis  has  become  developed.     This 

1  Practice,  fourth  edition,  p.  570.  "  Ibid,  cit.,  p.  209. 


CIRRHOSES    OF    THE    LIVER.  159 

statement  is  no  doubt  true,  and  can  be  shown  obviously  in  the  autopsy- 
room  on  rare  occasions.  When  it  comes  to  actual  clinical  work  and 
interpretation  I  am  obliged  to  confess  that  this  stated  hardness  as 
compared  with  softness,  where  the  large  liver  is  merely  congested,  is 
very  difficult  to  differentiate.  I  have  seen  many  cases  of  enlarged, 
smooth  liver  where  there  were  few  or  no  symptoms  of  ill  health,  unless, 
perhaps,  slight  evidences  of  dyspepsia  should  pass  for  such.  In  these 
cases  the  tactile  sensations,  so  far  as  relative  hardness  is  concerned, 
revealed  little  or  nothing  from  this  standpoint.  This  judgment  is  spe- 
cially correct,  I  am  confident,  where  the  patient  is  corpulent,  with  thick 
abdominal  walls,  due  to  the  deposit  of  adipose  tissue.  In  spare,  meagre 
individuals,  with  lack  of  muscular  tone  and  relaxed  abdominal  walls, 
the  problem  to  be  settled  is  much  easier,  and  we  may  indeed  say,  truth- 
fully, "  Liver  is  hard  or  liver  is  soft."  Of  course,  we  should  never 
expect  to  find  in  hypertrophic  cirrhosis  the  extreme  hardness  to  tactile 
sensations  which  is  characteristic  of  the  atrophic  form  ;  nor  is  it 
rational  to  expect  it  when  we  consider  the  very  great  difference  which 
exists  in  the  variety  of  the  fibrosis — fine  in  one  case,  coarse  in  the  other. 
The  same  cause — alcohol — which  produces  fibrosis  of  the  liver  also 
effects  interstitial  changes  in  other  abdominal  organs,  and  particularly 
the  kidneys,  which  are  thus  affected  in  a  large  proportion  of  cases. 

Despite  the  fact  that  it  is  affirmed  that  jaundice  does  not  occur  in 
atrophic  cirrhosis,  this  statement  cannot  on  inquiry  and  research  be 
confirmed.  On  the  contrary,  it  would  seem  as  though  we  may  and  do 
have  jaundice  in  all  forms  of  cirrhosis.  What  is  true  is  that  jaundice 
occurs  earlier  in  the  hypertrophic  form  than  it  does  in  the  atrophic, 
and  hence,  of  course,  when  it  does  show  itself  in  the  latter  form  it  is 
a  sign  of  very  bad  augury.  Many  of  the  particular  symptoms  given 
by  Hanot  to  designate  specially  his  form  of  biliary  cirrhosis  are  to  be 
met  with  in  the  ordinary  hypertrophic  form,  many  of  which  are  doubt- 
less alcoholic  ;  but  when  we  come  to  consider  the  whole  description  of 
this  writer  we  fail  to  find  him  in  accord  with  other  observers — mainly 
outside  of  France.  Even  the  hyperplasia  of  bile  ducts  which  Hanot 
considers  so  characteristic  may  be  found  in  other  forms.  The  jaundice 
does  not  always  occur  in  the  usual  hypertrophic  form,  nor,  again,  is 
ascites  always  absent,  and  the  spleen  may  not  be  visibly  enlarged. 
Pain  and  pyrexia  simply  show  advent  of  perihepatitis,  and,  although 
frequent  in  the  hypertrophic  form,  it  may  also  occur  in  other 
forms.  Nervous  phenomena  and  the  typhoid  state  are  more  frequent 
in  this  form,  but  they  are  not  absolutely  distinctive.  Chronicity  is 
not  coastant,  and,  as  we  see,  already,  cases  do  not  conform  in  all 
respects  to  a  purely  classical  type.  Where  alcohol  is  a  prominent 
factor  in  causation  the  symptoms  approximate  those  of  the  atrophic 
form.     No  doubt  in  just  such  instances  the  hypertrophic  liver  is  spe- 


160  CIRRHOSES    OF    THE    LIVER. 

cially  hard.  The  syphilitic  liver,  like  the  hypertrophic  form,  is  often 
enlarged,  extending  in  the  right  mammary  line  far  beyond  the  right  free 
margin  of  the  ribs.  If  gummata  are  present  they  may  be  recognized,  as 
already  stated,  by  the  distinct  irregularities  or  bossing  of  the  surface. 
If  instead  of  gummata  there  is  a  cirrhotic  process  due  to  syphilis,  the 
liver  may  also  present  a  swollen  appearance,  and  this  is  also  true  if 
amyloid  degeneration  has  become  manifest,  which  may  be.  shown  in 
advanced  syphilitic  conditions  of  the  liver.  In  both  syphilitic  cirrhosis 
and  amyloid  liver  the  organ  is  hard  and  relatively  smooth  (Einhorn), 
and  in  the  former  case  the  fibrosis  is  said  to  be  diffuse  and  monolobular. 
(Cheadle.)  Not  always  is  the  syphilitic  liver  large  ;  it  may  be  small, 
and  is  thus  often  confounded  with  the  alcoholic  liver.  This  is  especially 
to  be  regretted  from  a  therapeutic  standpoint,  knowing  as  we  do  how 
invaluable  antisyphilitic  treatment  is  in  these  cases.  Perihepatitis,  while 
not  pathognomonic  of  syphilitic  liver,  occurs  very  frequently  in  connec- 
tion with  it.  Moreover,  in  this  form  a  similar  condition  is  more  apt 
to  extend  to  other  organs,  particularly  to  the  peritoneum,  where  it 
causes  that  adhesive  inflammation  which  of  itself  is  quite  characteristic. 
Where  syphilitic  cirrhosis  exists  it  may  be  more  or  less  advanced. 
Indeed,  its  presence  may  only  be  revealed  by  a  slight  scarring  of  the 
free  surface  and  some  thickening  of  the  hepatic  capsule.  Such  patho- 
logical conditions  may  serve  to  fix  a  diagnosis  post-mortem  where  there 
has  been  no  syphilitic  history  and  where  signs  and  symptoms  during  life 
left  one  in  reasonable  doubt  as  to  the  etiology  of  the  case.  Inasmuch 
as  syphilis  of  the  liver  is  a  late  form  of  the  disease,  I  have  known 
instances  where  the  patient  seemed  almost  oblivious  of  his  ever  having 
had  it,  and  where  he  could  only  with  some  difficulty  be  made  to  under- 
stand any  connection  between  his  previous  history  and  his  actual  symp- 
tom?. I  am  now  having  in  mind  educated  and  fairly  intelligent  men 
of  the  world.  This  is  a  practical  observation  of  importance  from  the 
point  of  view  of  insistence  upon  antisyphilitic  treatment  at  times,  even 
though  the  patient  is  skeptical  and  disposed  to  resist  or  follow  out  his 
own  impressions  of  his  ailment.  No  organ  at  times  becomes  more 
important  in  the  history  of  hepatic  cirrhosis  than  the  heart.  As  soon 
as  it  shows  symptoms  even  of  dynamic  inefficiency  immediately  there 
is  a  tendency  to  venous  stagnation,  which  must  promote  growth  of 
fibrous  tissue  and  development  of  ascites.  Alcohol,  as  we  know,  affects 
the  heart  as-  it  does  other  organs  ;  but  here  it  seems  rather,  as  a  rule, 
to  produce  fatty  or  other  degeneration  of  the  muscular  fibres  than 
deposits  in  interstitial  tissues.  No  doubt  these  cardiac  changes  account 
for  many  sudden  deaths  in  syncope,  or  sudden  asthenia  otherwise  unex- 
plained. Frequent  stimulation  may  tide  over  some  of  these  attacks, 
but  to  be  effective  it  must  be  employed  without  delay. 

I  have  already  indicated  the  effect  of  alcohol  upon  many  abdominal 


CIRRH08E8    OF    THE    LIVER.  161 

organs.  Of  course,  we  can  understand  if  these  organs  are  much  impli- 
•  cated  their  influence  upon  the  rapid  march  of  hepatic  cirrhosis  is  greatly 
felt.  Hepatic  cirrhosis  is  particularly  liable  to  be  complicated  with 
acute  miliary  tuberculosis  of  some  organs,  and  very  many  patients  die 
from  this  rather  than  the  hepatic  disease  itself.  In  this  way  it  is  shown 
how  imperative  it  is  for  these  patients  to  keep  up  good  nutrition  and 
live  all  the  while  nearly  in  the  open  air.  The  statements  of  many 
observers  corroborate  this.  Thus  Osier  writes  :  "In  seven  of  my 
series  the  patients  died  with  either  acute  tuberculous  peritonitis  or 
acute  tuberculous  pleurisy."1  It  is  curious,  on  the  other  hand,  that 
distinguished  and  careful  clinicians  like  Flint  and  Fagge  apparently 
make  no  note  of  it. 

The  prognosis  of  hepatic  cirrhosis  has  usually  been  most  gloomy. 
Once  ascites  is  revealed  the  patient's  lease  of  life  appears  very 
limited.  To-day  we  are  more  encouraged  and  regard  certain  cases 
very  hopefully.  Even  in  the  advanced  cases  of  atrophic  cirrhosis  we 
cannot  always  be  sure  to  what  extent  some,  not  to  say  many,  of  the 
liver  cells  retain  good  functional  power — at  all  events,  power  sufficient 
to  help  continue  good  nutrition  if  attending  conditions  be  treated 
rationally. 

It  is  recognized  generally  that  we  have  no  remedy  which  will  make 
disappear  the  formation  of  fibrous  tissue  in  the  liver ;  but  the  ascites 
may  ba  removed,  even  in  these  extreme  cases,  and  allow  the  collateral 
circulation  to  act,  with  relief,  to  a  certain  degree,  of  the  obstructed 
portal  circulation.  Then,  every  time  effusion  becomes  considerable  and 
organs  are  interfered  with  in  their  action  through  pressure,  let  para- 
centesis be  repeated. 

It  has  been  shown  by  Fagge  that  cirrhosis  often  becomes  quiescent 
before  it  reaches  its  final  stage.2  Flint  seems  to  corroborate  this  view, 
because  he  says  emphatically  that  life  has  lasted  months  and  years  after 
ascites  had  become  developed  and  been  recognized.  Even  in  some 
atrophic  cases  of  advanced  type  nutrition  is  still  preserved,  and  this  is 
always  of  good  augury,  because,  despite  the  ascites,  it  shows  some  liver 
cells  able  to  function  normally.  Of  course,  there  is  a  possibility  in 
these  cases  that  we  have  not  to  do  with  a  true  cirrhosis  of  the  liver 
itself,  but  with  a  perihepatitis  or  chronic  peritonitis  which  was  very 
probably  the  cause  of  the  abdominal  effusion.  In  this  connection  I 
would  quote  Fagge3  again  to  corroborate  my  statement. 

In  hypertrophic  and  syphilitic  cirrhosis  the  prognosis  is  much  more 
hopeful.  In  the  former  case  the  development  of  fibrous  tissue  is  of 
immature  form,  and  occurs  more  rapidly  with  intercurrent  conspicuous 

i  Ibid,  cit.,  p.  571. 

8  Paper  read  before  British  Medical  Association,  1883,  vol.  ii.  p.  566. 

3  Practice  of  Medicine,  vol.  ii.  p.  315. 


162  CIRRHOSES    OF    THE    LIVER. 

cell  proliferation.  This  rapidly  formed  connective  tissue  is  never  so 
dense  nor  is  it  so  destructive  to  the  liver  cells  as  that  of  the  atrophic 
form  of  cirrhosis.  In  these  cases  there  is  often  relative  youth  and  good 
nutrition.  Hence,  from  all  these  standpoints  the  prognosis  is  more 
favorable. 

The  prognosis  of  hepatic  syphilis  is  even  more  hopeful.  Of  ten  cases 
reported  by  Einhorn  "  only  one  patient  died,  and  even  this  one  had 
been  considerably  benefited  for  five  or  six  months,  whereas  all  the 
others  were  either  perfectly  cured  or  much  improved."1 

Of  course,  if  cirrhosis  could  be  recognized  at  an  early  stage,  and 
before  the  advent  of  ascites,  the  outlook  would  not  be  immediately 
unfavorable.  Sometimes  we  are  able  to  make  this  diagnosis  from 
certain  prominent  signs  or  symptoms  :  the  indurated,  large  liver — an 
organ  enlarged — and  also  irregular,  vascular  stigmata  on  the  skin  and 
face,  and  passing  jaundice  ;  an  enlarged  heart,  constipation,  dyspeptic 
symptoms,  palpitations,  and,  it  may  be,  some  emaciation.  We  should 
act  in  accordance  with  the  manifest  indications,  and  among  these  is 
one  primary  and  essential  to  correct  absolutely — an  alcoholic  habit,  if, 
as  is  usual,  it  has  previously  existed. 

We  often  meet  with  combined  cases  of  alcoholic  and  syphilitic  cir- 
rhosis. Some  such  cases  have  been  known  to  recover  during  several 
years.  This  recovery  was  evident  through  subsidence  of  the  ascites 
and  recovery  of  the  general  health.     (Cheadle.) 

The  first  and  most  important  indication  of  useful  treatment  arises 
from  the  point  of  view  of  arresting  growth  of  fibrous  tissue  in  the  liver, 
and  in  this  way  the  preservation  of  the  remaining  healthy  liver  cells. 
This  is  accomplished,  if  at  all,  by  abandonment  of  the  use  of  alcohol, 
which  cannot  be  too  urgently  insisted  upon  in  the  great  majority  of  in- 
stances. Of  course,  there  may  arise  states  of  anaemia,  prostration,  or 
great  weakness  in  which  a  moderate  amount  of  good  alcoholic  stimu- 
lant may  be  imperatively  required,  at  least  for  a  time,  and  under  such 
circumstances  should  surely  not  be  withheld.  This  must  be  regarded 
merely  as  a  temporary  necessity,  and  we  must  have  in  view  constantly 
the  fact  that  it  has  been  shown  that  even  if  fatty  degeneration  of  liver 
cells  be  begun  it  will  often  be  arrested  if  alcohol  be  wholly  given  up. 
A  judiciously  arranged  dietary  is  only  of  secondary  importance,  and 
yet  it  is  undoubtedly  true  that  the  digestive  organs  must  be  supplied 
with  suitable  food  products,  properly  prepared,  to  sustain  active  nutri- 
tion and  to  ward  off,  as  far  as  may  be,  certain  functional  or  even 
organic  disturbances  in  part  dependent  upon  auto-intoxication  of 
gastro-intestinal  origin.  Fats  and  sugars  should  be  notably  diminished 
in  the  dietary,  for  the  reason  that  in  the  impaired  liver  functional  power 

i  Ibid.  cit. 


CIRRHOSE8    OF    THE    LIVER.  163 

is  decreased,  and  is  shown  especially  in  its  inability  for  proper  assimi- 
lation of  foods  containing  many  such  elements.  The  simplest  dietary 
of  milk,  eggs,  stewed  fruits,  well-cooked  fresh  vegetables,  and  the 
lighter  meats  is  of  decided  utility.  Semmola's  is  the  only  rational 
treatment,  viz.,  to  reduce  the  quantity  of  food  to  a  minimum  and  give 
it  in  a  form  which  will  tax  the  liver  cells  least.  Milk  is  undeniably 
the  best  of  all  ;  but  when  this  becomes  intolerable,  as  it  often  does, 
eggs  and  other  light  food  may  be  added.  No  doubt  some  instances  of 
cirrhosis  of  the  liver  originate  in  auto-inloxication  from  the  stomach 
and  bowels.  In  all  instances  aggravation  of  the  developed  disease  may 
result  from  it ;  hence  over  and  beyond  appropriate  dietary  the  use  of 
suitable  antiseptic  remedies  like  guaiaquin  and  benzosol  (Gasper)  may 
be  formally  indicated.  Among  drugs  which  have  a  decided  action, 
aad  one  most  beneficial  in  almost  all  syphilitic  cases,  iodide  of  potas 
sium  easily  ranks  first.  There  can  be  no  question,  in  view  of  very 
many  recorded  cases,  that  guramata  in  their  early  stages  are  reabsorbed 
through  its  action.  It  is  highly  probable,  also,  that  perihepatitis  and 
similar  conditions  of  other  abdominal  organs  (spleen,  peritoneum)  are 
very  favorably  affected.  It  is  not  a  sufficient  reason  to  proscribe  the  use 
of  the  iodide  because  the  syphilitic  nature  of  the  case  is  not  always  per- 
fectly clear.  In  many  instances  doubt  may  legitimately  exist.  Indeed, 
in  many  combined  alcoholic  and  syphilitic  cases  a  positive  differential 
diagnosis  as  to  how  much  is  due  to  alcohol,  how  much  caused  by 
syphilis,  is  impossible.  The  only  safe  rule,  then,  is  to  give  up  alcohol 
and  take  the  iodide.  Again,  in  instances  where  there  is  no  history  of 
syphilis  and  no  evidence  discoverable  of  its  presence,  it  is  yet  wise  at 
times  to  administer  the  iodide,  the  reason  being  that  purely  alcoholic1 
cases  and  those  due  to  syphilis  of  the  nature  of  an  interstitial  hepatitis 
are  often  confounded  one  with  the  other. 

In  the  event  of  evidences  of  heart  weakness,  and  in  view  of  the 
well-known  post-mortem  findings,  digitalis  and  heart  tonics  should  be 
employed  judiciously.  Salines  and  diuretics  are  of  some  use  in  the 
relief  of  ascites,  but,  as  a  rule,  are  of  more  value  in  warding  off  its 
return  for  a  while  after  paracentesis  than  in  preventing  the  necessity  of 
this  operation.  The  explanation  of  this  is  not  perfectly  clear,  although 
a  theory  for  it  may  be  readily  offered,  viz.,  that  the  absorbents  re- 
lieved from  pressure  are  more  efficient.2  Very  active  purgation  by 
the  use  of  hydragogue  cathartics  is  at  no  time  indicated,  as  it  is  useless 
and  may  become  directly  injurious  by  depleting  the  patient's  strength 
very  much  or  by  bringing  on  diarrhoea  often  difficult  to  arrest.     On 

1  Of  the  frequency  of  this  form,  one  may  judge  from  Flexner's  report  of  autopsies  done  at 
the  Philadelphia  Hospital.  Among  eighty-eight  cases  of  syphilis  of  the  liver,  forty  had  inter- 
stitial hepatitis.— Medical  Record,  October  19, 1901. 

2  Thromboses  of  the  portal  vein  may  cause  rapid  re-accumulation  of  ascites. 


164  CIRRHOSES    OF    THE    LIVER. 

the  other  hand,  the  moderate  use  of  mineral  waters  to  keep  the  bowels 
regular  may  be  very  necessary  to  the  patient's  welfare. 

In  the  treatment  of  hypertrophic  cirrhosis  Nothnagel  has  wisely 
insisted  upon  small,  repeated  doses  of  calomel.  Vaughan  believes  that 
later  this  form  of  disease  will  be  treated  mainly  by  surgery,  as  it  is  the 
only  way  by  which  the  gall-bladder  and  biliary  vessels  can  be  disin- 
fected. 

Billings  quotes  Kussmaul  as  using  chloride  of  ammonium  to  prevent 
proliferation  of  the  connective  tissue  cells,  and  he  (B.)  claims  in  this 
way  he  has  seen  induration  of  the  liver  disappear  as  well  as  some  local 
symptoms  connected  with  the  disease. 

Whatever  may  have  been  the  objections  in  former  years  to  paracen- 
tesis, legitimate  or  unsupported,  to-day  it  seems  very  clear  that  in  early 
and  repeated  paracentesis  the  best  hope  of  the  patient  lies.  Even  in 
advanced  instances  of  atrophic  cirrhosis  life  is  prolonged  and  suffering 
diminished  ;  but  in  instances  where  we  have  an  enlarged  liver  with 
ascites,  which  in  such  cases  often  occurs  when  the  disease  is  not  far 
advanced,  we  get  our  best  results  from  paracentesis.  The  fluid  may 
recur  in  smaller  quantity  after  each  paracentesis,  and  in  some 
undoubted  examples,  after  several  operations,  no  fluid  has  recurred, 
and  so  far  as  symptoms  are  concerned,  we  may  properly  say  a  recov- 
ery has  taken  place.  This  may  last  for  many  years.  I  have  had 
at  least  one  such  instance  in  my  practice.  The  patient  recovered 
from  the  ascites,  and  subsequently  died  of  another  disease  than  hepatic 
cirrhosis,  as  was  evident  at  the  autopsy.  The  danger  to-day  of  peri- 
tonitis arising  from  paracentesis  is  very  slight,  indeed,  if  ordinary 
aseptic  precautions  be  observed.  I  do  believe  it  is  wiser  to  employ  the 
ordinary  aspirator  or  Flint's  modification  of  the  Davidson  syringe, 
than  the  trocar  and  canula,  and  mainly  because  the  flow  of  fluid  is 
easily  regulated,  and  thus  there  is  less  danger  of  syncope  or  heart 
failure,  which  might  be  directly  caused  by  too  rapid  evacuation  of  fluid 
where  cardiac  degeneration  is  present.  This  accident  may  also  be 
obviated,  as  we  know,  by  the  prompt  use  of  a  binder  as  the  fluid  flows 
from  the  abdomen.  The  binder  also  is  useful  in  delaying  return  of 
ascites.  There  is  less  risk  of  serious  injury  to  the  intestines  with  the 
small  needle  attached  to  the  aspirator  than  with  a  moderate-sized  trocar.1 

Unfortunately,  paracentesis  is  not  always  thoroughly  satisfactory. 
The  canula  may  become  blocked  in  different  ways  and  for  different 
reasons,  not  always  easy  to  obviate.  In  our  very  desire  to  benefit  our 
patient  and  withdraw  most  of  the  fluid  from  the  cavity  we  may  run 
the  risk  of  wounding  the  intestine.  Sometimes  the  cause  of  the  obstruc- 
tion of  the  canula  is  a  piece  of  false  membrane ;  again  it  seems  to  be  the 

i  British  Medical  Journal,  1883. 


CIRRH08ES    OF    THE    LIVER.  165 

intestinal  wall,  and  we  must  be  careful  not  to  injure  it.  In  some  in- 
stances where  we  expect  to  obtain  a  large  quantity  of  fluid  we  really 
get  very  little,  which  is  discouragiug  both  to  patient  and  physician. 
Occasionally  it  seems  as  though  the  posture  of  the  patient  was  respon- 
sible for  this,  but  I  have  found  the  difficulty  to  arise  when  the  patient 
was  sitting  up  and  also  when  the  patient  was  lying  down. 

Some  authors  have  objected  to  paracentesis  because,  they  say,  after 
it  the  ascites  recurs  more  rapidly,  and  that,  besides  the  risks  alluded 
to,  it  is  very  depressing  through  loss  of  albumin  from  the  blood  on 
every  occasion  it  is  performed.  This  objection  has  little  or  no  value, 
as  a  rule,  especially  if  the  patient  be  in  fairly  good  general  condition. 
Of  course,  if  the  patient  is  very  old  and  feeble,  or  the  disease  very 
advanced,  paracentesis  is  likely  to  hasten  the  fatal  termination.  On 
the  other  hand,  where  the  abdominal  and  thoracic  organs  have  been 
compressed  or  pushed  away  from  their  normal  position  by  excess  of 
abdominal  fluid  there  is  no  question  that  the  fluid  should  be  speedily 
removed.  Thus  great  distress  is  often  relieved,  the  kidneys  begin  to 
function  with  renewed  activity,  and  the  general  condition  of  the  patient 
is  notably  improved.  The  lungs  are  enabled  to  breathe  freely  again, 
and  the  heart  becomes  regular  and  fails  to  intermit.  While  getting 
additional  power  very  rapidly,  cough,  expectoration,  hypostasis,  and 
even  pleuritic  effusion  due  to  upward  pressure  soon  disappear.  Some- 
times after  paracentesis  there  is  more  or  less  leakage  from  the  abdomen 
through  the  hole  made  with  the  needle  or  trocar.  This  is  often  very 
annoying  to  the  patient,  as  his  clothes  and  bedding  become  thoroughly 
wet ;  and  yet  it  may  be  useful  in  a  few  instances  from  the  fact  that 
the  drainage  continues  for  several  hours  after  the  operation  is 
concluded,  and  from  regions  the  needle  could  not  reach.  In  this 
connection  it  is  proper  to  refer  to  continuous  abdominal  drainage 
by  means  of  a  permanent  canula  left  in  the  abdomen  after  the  trocar 
is  withdrawn.  I  performed  this  operation  on  one  occasion,  with 
apparently  some  good  result ;  but  the  dangers  from  aspiration  of  air 
into  the  cavity,  peritonitis,  and  suppuration  are  such  that  I  felt  later 
that  better  ultimate  results  could  be  expected  from  repeated  puncture 
and  before  the  fluid  was  permitted  to  reaccumulate  in  too  large  quan- 
tity, or  caused  any  notable  distress,  or  interfered  much  with  the  healthy 
function  of  any  important  organ. 

-"  The  removal  of  fluid  by  continuous  drainage  has  been  practised 
with  some  success  by  Dr.  Caille  and  Dr.  Elliot  in  America,  and  by  Dr. 
Urso  in  Italy."1  And  certainly  in  some  cases  it  would  appear  to  be 
safer  and  quite  as  effective  as  the  radical  operation  to  produce  new 
anastomoses. 

On  the  other  hand,  Weir,2  who  used  permanent  drainage  in  connec- 

1  Cheadle,  p.  88.  2  The  American  Journal  of  the  Medical  Sciences,  1899,  p.  723. 


166  CIRRHOSES    OF    THE    LIVER. 

tion  with  or  rather  subsequent  to  the  radical  operation,  "  would  here- 
after prefer  to  resort  to  paracentesis  if  it  became  necessary,  as  the  risk 
seems  less." 

It  is  surprising  at  times  to  remark  the  powerful  diuretic  effect  of 
paracentesis.  Kidneys  that  previous  to  it  were  inactive  become  active, 
urine  that  was  albuminous,  of  high  specific  gravity,  and  contained  casts 
accompanied  by  urcemic  symptoms,  has  changed  remarkably.  The 
flow  of  urine  has  wonderfully  increased  in  quantity,  and  its  characters 
have  become  almost  normal,  while  all  ursemic  evidences  have  soon  disap- 
peared. Without  the  paracentesis  both  purgatives  and  diuretics  seemed 
wholly  worthless  to  produce  these  much-desired  effects. 

If  we  wish  to  get  the  best  effects  from  repeated  tapping  we  must  have 
patients  under  our  immediate  care,  so  that  they  may  be  tapped  again 
when  the  proper  moment  arrives.  Tapping  should  be  repeated  in 
proper  cases  until  fluid  ceases  to  reaccumulate.  During  this  period 
it  should  be  our  effort  to  maintain  the  patient's  nutrition  to  the  highest 
degree  possible.  Through  constant  care  and  attention  we  obtain  the 
best  results  ;  through  carelessness  or  permitting  the  patient  to  absent 
himself  too  long  from  observation  we  have  often  cause  for  regret,  and 
the  patient  relapses  into  an  impoverished  and  threatening  state. 

On  the  other  hand,  Hale  White's  observations  would  go  to  show 
"  that  in  the  cases  of  cirrhosis  of  the  liver  with  chronic  peritonitis  the 
survival  for  a  considerable  length  of  time  was  due  to  the  fact  that  the 
latter  lesion  assists  in  some  way  in  the  formation  of  a  collateral  circu- 
lation."1 

Now,  as  Osier  writes  :  "  We  know  that  extreme  grades  of  contraction 
of  the  liver  may  persist  for  years  without  symptoms  when  the  com- 
pensatory circulation  exists.  The  so-called  cure  of  cirrhosis  means  the 
re- establishment  of  this  compensation."2 

Upon  this  idea  of  re-establishment  of  this  compensation  rests  the 
modern  radical  surgical  treatment  of  cirrhosis  of  the  liver.  The  method 
is  to  promote  adhesions  between  the  liver,  spleen,  and  abdominal  walls 
and  diaphragm,  thus  helping  collateral  circulation  by  new  vascular 
channels.  This  is  attempted,  first,  by  completely  evacuating  the 
abdominal  contents,  and  then,  by  thorough  scrubbing  of  the  organs 
referred  to,  set  up  a  certain  amount  of  irritation  which  shall  tend  to 
make  the  formation  of  new  vessels  more  probable.  In  this  connection 
Cheadle  is  of  the  opinion  that  if  we  consider  the  conditions  where  the 
new  vessels  are  found  naturally  they  do  not  seem  favorable,  being, 
associated  with  the  worst  cases,  and  do  not  lead  one  to  try  to  produce 
them  artificially.     Opposed  to  this  view  we  would  cite    three  cases- 

i  The  American  Journal  of  the  Medical  Sciences,  March,  1901,  p.  259. 
2  Ibid,  cit.,  p.  566. 


CIRRHOSES    OF    THE    LIVER.  167 

cured  :  one  of  Osier's,1  operated  on  by  Dr.  Bloodgood  at  Johns  Hopkins 
Hospital ;  another  of  Brown's,2  another  of  Frazier's.3  In  one  instance 
under  my  care,  operated  on  by  Dr.  F.  H.  Markoe,  nearly  two  years 
ago,  the  patient  has  had  recurrent  ascites,  necessitating  repeated  tap- 
pings since  the  radical  operation.  Two  of  Osier's  cases  were  unsuc- 
cessful. As  regards  one  or  two  tappings  after  the  operation,  this  we 
should  expect  where  a  drainage-tube  has  not  been  introduced,  the 
reason  being  that  time  is  required  for  the  formation  of  adhesions  and 
new  veins  ;  and  the  introduction  of  the  drainage-tube  is  now  shown  to 
be  bad  from  a  surgical  standpoint,  as  it  opens  a  channel  of  infection. 
(Frazier.) 

In  Dr.  Brown's  successful  case,  at  first  referred  to  in  the  Presbyterian 
Hospital  Reports  for  1900,  and  the  patient  subsequently  presented  at  a 
meeting  of  the  New  York  State  Medical  Society,  held  October  16, 1901, 
at  the  New  York  Academy  of  Medicine,  the  condition  was  one  of 
atrophic  cirrhosis,  due  to  alcohol.  There  was  no  syphilis  and  no  malaria, 
although  the  spleen  was  enlarged.  There  was  no  pronounced  venous 
engorgement  on  the  abdominal  walls.  The  patient  was  operated  upon 
over  two  years  ago.  There  has  been  no  recurrence  of  ascites,  and  the 
nutrition  remains  good.  The  patient  is  doing  his  usual  work — that 
of  a  day  laborer. 

Frazier4  in  the  remarks  he  makes,  prompted  no  doubt  by  a  success- 
ful case,  wisely  insists,  as  a  formal  contraindication  to  the  operation, 
upon  the  absolute  lack  of  functional  power  in  the  liver  cells — i.  e.y 
shown  usually  by  extreme  atrophy.  (Packard.)  In  his  judgment,  the 
presence  of  cardiac  and  renal  degeneration  is  only  a  relative  contra- 
indication. He  also  states  that  it  is  essential,  in  order  to  avoid  fatal 
toxaemia,  that  the  collateral  circulation  should  be  formed  gradually. 
Where  the  cases  have  been  carefully  selected  he  "  believes  the  opera- 
tion has  a  future." 

Fourteen  cases  are  thus  far  reported,  seven  of  which  appear  to  have 
been  materially  benefited  or  cured  by  the  operation  (Brown)  and  three 
died  from  the  operation.5  "  The  many  instances  of  practical  cure  fol- 
lowing tapping,  and  the  uncertainty  of  the  exact  pathological  state  of 
the  liver,  together  with  the  somewhat  formidable  character  of  the  opera- 
tion and  liability  of  infection,  invest  the  operation  at  present  with  a. 
large  element  of  doubtful  expediency."6  These  remarks,  cited  textu- 
ally  from  Dr.  J.  D.  Bryant's  work  on  Operative  Surgery,  appear  to  me 
eminently  wise. 

1  Ibid,  cit.,  p.  577.  -  New  York  Medical  Eecord,  October  19, 1901,  p.  637. 

3  The  American  Journal  of  the  Medical  Sciences,  December,  1900,  p.  661.  4  Loc.  cit. 

6  Later  Packard  reports  twenty-two  cases,  with  nine  recoveries  and  eight  deaths  (The 
American  Journal  of  the  Medical  Sciences,  March,  1901,  p.  265),  and  in  a  "note"  one 
death— one  doubtful. 

6  Bryant,  Operative  Surgery,  1901,  vol.  ii.  pp.  802,  803. 


168  CTBEHOSES    OF    THE    LIVEE. 

la  all  these  cases,  moreover,  it  is  judicious  to  properly  estimate  the 
amount  of  functional  disturbance,  if  possible,  of  the  liver  cells  (icterus, 
acholic  stools,  urobilinuria,  etc.)  as  well  as  the  physical  changes  of  the 
liver  itself.  In  it  may  be  found,  as  Brown  says,  a  formal  contraindi- 
cation to  the  wisdom  of  the  operation.  Neumann1  also  wisely  insists 
"  that  the  liver  cells  be  not  too  greatly  impaired  in  their  functional 
capacities,  and  that  every  precaution  should  be  taken  in  selecting 
proper  cases,  in  order  not  to  permit  discredit  to  fall  upon  so  valuable 
an  operation." 

Brown  "  feels  assured  that  the  great  risks  attending  operations  on 
advanced  and  failing  cases  will  be  notably  wanting  in  similar  pro- 
cedures applied  in  earlier  stages  of  the  disease."2  No  doubt  this  state- 
ment is  correct,  but  in  my  judgment  it  is  correct  only  so  far  as  it 
applies  to  all  important  or  dangerous  surgical  procedures.  The  great 
difficulty  is  to  convince  the  pure  physician  with  the  facts  as  reported 
up  to  date,  and  allowing  for  errors  of  diagnosis  with  respect  of  the  pre- 
cise nature  of  the  liver  condition  and  for  the  concomitant  conditions 
almost  always  present  (heart,  kidneys,  spleen,  pancreas,  etc.)  that  such 
a  stand  is  justified.  I  am  scarcely  of  that  opinion  until  it  be  shown 
that  the  radical  operation  in  similar  instances  gives  better  results  than 
the  far  less  serious  procedure  of  simple  and  repeated  paracentesis. 

Dr.  Weir's  standpoint  appears  to  be  a  more  rational  one,  viz.,  "  The 
operation  was  worthy  of  trial  in  apparently  hopeless  cases  of  liver 
cirrhosis  in  which  the  abdomen  rapidly  refilled  after  repeated  tapping, 
and  in  which  the  large  quantity  of  the  fluid  was  producing  fatal 
exhaustion."3 

Dr.  McBurney  in  discussing  Dr.  Weir's  paper  thought  that  analogy 
with  what  occurred  after  simple  incision  in  cases  of  tuberculous  peri- 
tonitis allowed  one  to  question  whether  the  relief  of  ascites  in  cirrhosis 
of  the  liver  which  followed  the  radical  operation  was  brought  about 
by  the  development  and  growth  of  vascular  anastomoses.  This  view 
of  McBurney's  seems  to  approximate  that  of  Dr.  Osborne,  of  New 
Haven,  and  of  Dr.  Cheadle,  already  cited. 

On  the  other  hand,  Packard  and  Le  Conte4  claim  that  "  one  of  the 
ways  by  which  repeated  tappings  may  aid  in  the  recovery  of  cases  of 
cirrhosis  of  the  liver  is  through  the  formation  of  adhesions  similar  to 
those  aimed  at  in  the  operative  procedure,  but  to  a  less  degree."  Be 
these  views  as  they  may,  I  cordially  assent  to  their  previous  state- 
ment,5 that  "  these  cases  of  advanced  cirrhosis  of  the  liver,  operated 
on  or  not,  die  with  evidence  of  progressive  toxaemia  and  gradual  failure 
of  all  the  organs  to  do  their  proper  work." 

i  Quoted  by  Brown  (p.  11).  2  Page  16. 

3  New  York  Medical  Record,  January  28, 1899,  p.  143. 

4  The  American  Journal  of  the  Medical  Sciences,  March,  1901.  6  Ibid.,  p.  257. 


CIRRHOSES    OF    THE    LIVER.  169 

Despite  these  views,  they  state  in  their  conclusions,  as  their  opinion, 
"  that  where  the  diagnosis  of  pure  portal  cirrhosis  of  the  liver  can  be 
made,  and  where  persistent  and  well-directed  medical  treatment  is 
productive  of  insignificant  results,  the  operation  should  be  strongly 
recommended." 

Here,  it  seems  to  me,  the  great  difficulty  lies  in  this  precise  diagnosis 
at  the  present  time  ;  for  do  we  not  know  that  constantly  our  autopsies 
show  that  concomitant  lesions  exist  which  render  nugatory  all  radical 
op3ration3 — i.  e.,  other  kinds  of  cirrhosis,  chronic  peritonitis,  advanced 
degeneration  of  other  organs,  like  the  heart  and  kidneys,  etc.  ? 

There  can  be  little  doubt  that  in  very  many  cases  of  hepatic  cir- 
rhosis it  is  important  to  do  what  we  can  medicinally  and  otherwise  to 
keep  the  heart  in  a  vigorous  state.  Once  it  becomes  inefficient  func- 
tioually,  either  because  of  simple  dynamic  weakness  or  owing  to  struc- 
tural changes,  the  development  of  the  ascites  is  certainly  more  rapid 
and  more  apt  to  recur.  We  recognize  in  this  way  that  the  obstructed 
portal  circulation  due  to  fibrosis  is  also  heightened  notably  by  venous 
stagnation  caused  directly  by  impaired  heart  power.  '  No  doubt  the 
explanation  of  instances  of  early  effusion  in  hypertrophic  cirrhosis  is 
thus  often  satisfactorily  given.  If  such  a  view  be  admitted  it  can  be 
readily  understood  why  we  can  obtain  good  effects  from  suitable  treat- 
ment in  just  such  cases.  An  important  part  of  this  treatment  must  be 
the  maintenance  of  sufficient  cardiac  power  if  it  be  possible  to  prevent 
venous  stagnation  in  the  liver. 

In  instances  where  venous  stagnation  occurs  of  cardiac  origin  the  hepa- 
tic veins  at  the  centre  of  the  lobules  are  especially  affected,  and  it  is  also 
true  in  these  instances  that  here  is  likely  to  be  formed  the  fine  fibrous 
deposit  which,  as  we  have  seen,  characterizes  hypertrophic  cirrhosis. 
Not  always  is  the  cardiac  inefficiency  shown  by  evident  physical  signs, 
nor,  indeed,  by  the  presence  of  ascites  ;  still,  in  hypertrophic  cirrhosis 
or  simple  engorged  liver  it  is  a  safe  plan  to  give,  for  a  while  at  least, 
small,  repeated  doses  of  digitalis,  and  note  its  obvious  effects  either  on 
the  size  of  the  liver  directly  or  some  of  the  suggestive  symptoms  con- 
nected therewith. 

Appended  are  histories  of  cases  of  "  omental  anastomosis." 

Case  I. — Case  of  cirrhosis  of  the  liver  in  which  radical  operation 
was  performed  by  Dr.  F.  H.  Markoe.  J.  S.,  aged  fifty  years,  married  ; 
hotel  steward  ;  born  in  the  United  States  ;  admitted  to  St.  Luke's 
Hospital  June  30,  1898.  Alcoholic  history  ;  suffering  from  ascites. 
Liver  probably  enlarged  ;  rough  and  nodular.  Abdomen  much  dis- 
tended ;  evidences  of  fluid  ;  superficial  veins  enlarged. 

First  Aspiration.  Three  days  after  admission,  125  ounces  obtained  ; 
second  :  eleven  days  later  128  ounces  obtained. 

Treatment  nil.  Left  hospital  July  22,  1898  ;  re-entered,  December 
6,  1898. 

12 


170  CIRRHOSES    OF    THE    LIVER. 

Abdominal  fluid  increased  in  quantity  as  compared  with  quantity 
before  the  last  tapping,  July,  1898. 

Third  Aspiration.  Two  days  after  admission,  370  ounces  obtained  ; 
fourth  :  five  weeks  after  admission,  400  ounces  obtained  ;  fifth  :  seven 
and  a  half  weeks  after  admission  440  ounces  obtained  ;  sixth  :  ten  and 
a  half  weeks  after  admission,  475  ounces  obtained. 

Treatment.  Digitalis,  iodide  of  potash,  theobromine,  copaiba,  etc. 
Left  hospital  March  1,  1899,  and  readmitted  two  weeks  later;  abdo- 
men greatly  distended. 

Seventh  Aspiration.  Day  after  admission ;  390  ounces  obtained. 
Left  hospital,  and  readmitted  April  17,  1899. 

Eighth  Aspiration.     Day  admitted  ;  426  ounces  obtained. 

May  13th.    Ninth  :  390  ounces  obtained. 

Jane  14:th.    Tenth  :  450  ounces  obtained. 

July  10th.    Eleventh  :  330  ounces  obtained. 

August  12th.    Twelfth  :  452  ounces  obtained. 

October  1th.    Thirteenth  :  520  ounces  obtained. 

November  lMh.    Fourteenth  :  510  ounces  obtained. 

Treatment.     Codeine  for  cough. 

January  22, 1900,  Dr.  F.  H.  Markoe  performed  upon  the  patient  the 
operation  of  "  omental  anastomosis,"  and  500  ounces  of  light  yellowish 
fluid  slowly  evacuated  from  the  abdomen.  On  palpation,  the  liver 
was  found  large  ;  also  some  abdominal  adhesions.  Vomiting  of  green 
fluid  off  and  on  for  six  days  following  operation. 

Fourteenth  Aspiration.  Six  weeks  after  operation  ;  138  ounces  ob- 
tained. 

Subsequently,  up  to  November,  1901  (twenty-two  months  later), 
patient  has  been  aspirated  about  fifteen  to  seventeen  times,  which,  with 
those  performed  before  operation,  make  about  thirty  in  all. 

November,  1901.  He  is  now  confined  to  bed,  and  is  unable  to  leave 
it  by  reason  of  asthenia.1 

Case  II. — A  second  case  of  "  omental  anastomosis  "  for  cirrhosis  of 
the  liver  was  performed  by  Dr.  F.  H.  Markoe  at  St.  Luke's  Hospital, 
April  27,  1901.  The  patient  had  marked  ascites  ;  was  a  boy,  aged  thir- 
teen years,  and  had  been  quite  a  drinker.  Subsequent  to  the  operation 
the  patient  was  tapped  once  before  he  left  the  hospital,  on  May  21, 
1901.  Since  that  date  he  has  returned  about  every  six  weeks  to  have 
the  fluid  removed  from  the  abdominal  cavity.  The  patient's  general 
condition  is  about  the  same  as  before  the  operation.  The  ascites  is 
probably  somewhat  less. 

Case  III.— The  following  case  of  "  omental  anastomosis  "  is  one  in 
which  Dr.  F.  W.  Murray  operated. 

History.  P.  A.  B.,  married,  aged  forty-eight  years;  no  specific  dis- 
ease ;  excessive  alcoholic  habits. 

Four  months  before  admission  to  St.  Luke's  Hospital  patient  noticed 
yellow  conjunctivae  and  loss  of  flesh  and  strength.  His  abdomen 
increased  by  eight  inches  in  size.  This  increase  subsided  for  a  time 
under  calomel  and  salines,  but  soon  returned.  April  2,  1900,  entered 
hospital ;  328  ounces  of  fluid  removed  by  tapping  ;  largely  reaccumu- 
lated  in  two  or  three  days.     Transferred  to  surgical  service  April  18th. 

Abdomen  measured  44£  inches  at  a  point  three  and  a  half  inches 

1  Patient  died  December  15,  1901,  from  heart  failure. 


CIRRHOSE8    OF    THE    LIVER.  171 

above  the  umbilicus  ;  percussion  flat  over  the  whole  abdomen.  Opera- 
tion April  19th,  by  Dr.  Murray.  Incision  four  inches  long  at  the 
left  of  the  umbilicus  ;  3}  gallons  of  fluid  removed  ;  omentum  thick- 
ened and  vessels  injected  ;  sutured  to  parietal  peritoneum  by  five  inter- 
rupted sutures  of  No.  1  catgut ;  stood  operation  well.  Urine  acid  ; 
specific  gravity,  1020;  slight  trace  of  albumin;  no  sugar;  few  hyaline 
casts. 

Aspirated  April  23,  and  64  ounces  of  fluid  obtained.  April  30th, 
circumference  39  inches.  May  2d,  primary  union  of  wounds.  May 
12th,  oedema  of  feet ;  stuporous ;  pulse  rapid ;  coryza  marked ; 
erythema  over  nose,  diagnosed  as  erysipelas.  May  13th,  temperature 
between  98.3°  and  99°  F.  Pulse  varies  from  90  to  100.  Respiration, 
24.     Died.     (Above  history  furnished  by  Dr.  Martin.) 

Note. — Since  writing  the  foregoing  paper  a  valuable  contribution 
from  the  pen  of  Dr.  George  E.  Brewer,  on  "  The  Surgical  Treatment 
of  Ascites  Due  to  Cirrhosis  of  the  Liver,"  has  been  published.  From 
it  we  take  the  report  of  "  5  personal  cases  and  analyses  in  tabular  form 
from  about  50  more  from  the  literature."  From  reviewing  these  statis- 
tics Brewer  finds  at  least  6  patients  who  have  been  cured  of  ascites  by 
this  procedure — i  e.,  Talma-Morrison  operation — and  who  have  re- 
mained well  for  two  years  or  more ;  6  others  have  died,  with  relief  of 
this  symptom  from  two  to  six  months  before  death,  or  who  had  not 
been  under  observation  long  enough  to  demonstrate  a  permanent  cure. 
Another  patient  suffering  from  hemorrhage  of  the  alimentary  canal 
was  promptly  cured  by  this  operation.  Many  others  have  been  mate- 
rially benefited  ;  38  have  recovered  from  the  operation  ;  and,  consid- 
ering that  the  great  majority  of  these  were  within  a  few  weeks  of 
inevitable  death,  he  thinks  that  it  should  encourage  us  to  suggest 
operation  at  an  earlier  and  more  favorable  stage  of  the  disease.  If 
this  suggestion  is  followed  he  believes  that  statistics  will  show  a  great 
improvement  over  those  he  is  able  at  this  time  to  present.1 

In  a  later  contribution  on  this  subject  Dr.  W.  Murrell,  of  Westmin- 
ster, writes2  that  "  much  depends  on  careful  selection,  and  the  best 
results  would  probably  be  obtained  in  the  pre-ascitic  stage  when  the 
diagnosis  rests  on  the  alcoholic  history,  with  haematemesis  and  enlarge- 
ment of  the  liver  and  spleen." 

1  Journal  of  the  American  Medical  Association,  February  22,  1902,  p.  135. 

2  Lancet,  June  7,  1902,  p.  1604. 


C'OVj.  I. 


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